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TH« LISftARY 
 
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 EARL C. VAN DERWERKER, M. D. 
 
 125 WEST 58TH STREET 
 
 NEW YORK 
 
 THE TREATMENT 
 
 LATERAL CURVATURE OF THE SPINE. 
 
THM LI MARY 
 
 18 H or 
 
 £rcL> h'w«. ;TaL 
 
 THE TREATMENT 
 
 LATERAL CURVATURE 
 
 THE SPINE, 
 
 APPENDIX 
 
 THE TREATMENT OF FLAT-FOOT. 
 
 BERNARD ROTH, F.R.C.S., 
 
 FELLOW OF MEDICAL SOCIETY OF MKDOIT; MEMBER OF THE CLINICAL AND PATHOLOGICAL 
 SOCIETIES AND OF THE MEDICAL OFFICERS OF SCHOOLS ASSOCIATION. 
 
 LONDON: 
 
 H. K. LEWIS, 136, GOWER STREET, W.O. 
 
 L889. 
 
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PREFACE. 
 
 Although my views on the prognosis and treat- 
 ment of Lateral Curvature of the Spine have 
 undergone considerable modification during the 
 fourteen years I have been engaged in orthopaedic 
 practice, this monograph is mainly based on the 
 article " Lateral Curvature of the Spine " which 
 I contributed to Mr. C. Heath's "Dictionary of 
 Practical Surgery," 1886; on the papers published 
 in the British Medical Journal, u The Treatment 
 of Lateral Curvature of the Spine," May 13th, 
 1882 ; " Two Hundred Consecutive Cases of Lateral 
 Curvature of the Spine treated without Mechanical 
 Supports," October 31st, 1885; and " Scoliosiometry, 
 or, An Accurate and Practical Method of Recording 
 Cases of Lateral Curvature of the Spine," October 
 27th, 1888 ; and on the paper read before the 
 Clinical Society (April 13th, 1883), "A Case of 
 Lateral Curvature of the Spine, illustrating its 
 Treatment without the Use of Mechanical Sup- 
 ports " (vol. xvi. Clin. Soc. Trans., 1883). 
 
 Bernard Roth. 
 
 29, Queen Anne Street, 
 
 Cavendish Square, London, W. 
 
 February, 1889. 
 
Note. — All six photographs of Case 1. were taken the same morning 
 before commencing treatment. Photographs 1, 2, and 3 represent 
 the " habitual " posture of the patient ; and photographs i, 5, and 6 
 represent the " best possible " posture of the same patient after she 
 had been so placed by the Author. This improved posture could 
 only be maintained for the second or two required for taking the 
 photographs. 
 
* 
 
a girl, aged 7 years, with severe osseous 
 Lateral Curvature of the Spine, 
 in the "Habitual" posture. 
 
_ 
 
 8. 
 
 The same patjent as photograph (7), 
 when placed in the " key-note " 
 
 POSTURE {see page 12). 
 
TREATMENT 
 
 OF 
 
 LATERAL CURVATURE OF THE SPIKE. 
 
 Lateral curvature of the spine is a deformity due 
 to lateral deviation and distortion of the spinal 
 column, nearly always accompanied by more or 
 less exaggeration or diminution of the normal 
 antero-posterior curves. 
 
 This deformity is predisposed to by weakness 
 of the spinal muscles combined with long-continued 
 sitting or standing in stooping or relaxed positions, 
 such as standing on one leg, sitting writing and 
 reading with the trunk leaning to one side (see 
 figs. 1 and 3) or with the thighs crossed. 
 
 The position of writing, as generally practised, 
 is, more frequently than anything else, an initial 
 cause of lateral and other curvatures not due to 
 diseased bone. The much larger proportion of 
 girls than of boys affected is due to the fact that 
 girls do not enjoy, as a rule, one- fourth of the usual 
 amount of physical exercise, as cricket, football, 
 etc., allowed to boys. Their muscles either never 
 develop as they ought, or become weak; and, 
 although they sit no worse than boys at their 
 lessons, they have not sufficient strength to hold 
 
 1 
 
•2 
 
 TREATMENT OF 
 
 themselves erect and to restore the balance of 
 their curved backs out of school-hours. At the 
 onset of puberty, the development of girls generally 
 throws a greater strain on their health and strength 
 than is the case with boys. 
 
 Inequality in the lengths of the lower extremities 
 from various causes predisposes to lateral curvature 
 equally in both sexes. Such causes of inequality 
 
 Fig. 1. 
 
 
 Faulty Position at an Proper Position at 
 
 ordinary desk. Glendenning's Patent 
 
 Adjustable Desk. 
 
 in the legs may be either cougenital difference 
 in size, atrophy from infantile paralysis, hip-joint 
 disease, or congenital hip dislocation. 
 
 I have frequently observed a hereditary pre- 
 disposition to lateral curvature, due to an inherited 
 weakness of the muscles and ligaments, probably 
 associated with an excessive softness of the bones. 
 
 Eickets is frequently a cause of lateral curvature, 
 especially in very young children. As a general 
 rule, anything which weakens the muscular system 
 
LATERAL CURVATURE OF THE SPINE. d 
 
 tends to produce lateral curvature, which often 
 therefore follows convalescence after whooping- 
 cough, chicken-pox, measles, diphtheria, and 
 scarlet fever. 
 
 No satisfactory explanation has yet been given 
 why the large majority of cases of lateral curvature 
 have the upper or dorsal lateral curve with the 
 convexity to *the right. It is very probable that 
 
 Pig. 3. 
 
 Fie-. 4. 
 
 Faulty Position at an 
 ordinary desk. 
 
 Proper Position at 
 
 (llendenning's Patent 
 
 Adjustable Desk. 
 
 the greater use of the right arm and hand is 
 a predisposing cause, although, at the same time, 
 it must be admitted that cases with the convexity 
 of the upper or dorsal lateral curve to the left are 
 not at all limited to left-handed patients. Besides, 
 most cases of early lateral curvature (i.e., before 
 osseous deformity is well marked) are either 
 wholly convex to the left or have the lower or 
 lumbar curve convex to the left. 
 
 Pain in the back, generally of the loins or under 
 
4 TREATMENT OF 
 
 one shoulder-blade, is the first symptom observed 
 in a large number of cases ; the pain is either a 
 dull aching or bruised feeling ; at times it is very 
 sharp and acute, like ordinary neuralgia. In an 
 equally large number of cases, no pain or ache is 
 felt at first ; and some deformity, as the undue pro- 
 minence of a shoulder-blade or of a hip-bone 
 (iliac crest) 5 or general stooping, first directs 
 attention to the presence of lateral curvature. It 
 may be stated generally that the amount of pain 
 complained of is seldom in proportion to the 
 amount of deformity. Cases of extreme lateral 
 curvature are sometimes seen where there is not, 
 and never has been, any pain felt by the patient, 
 although the health may have been affected in 
 other ways : by indigestion, headache, shortness 
 of breath, etc. On the other hand, life may have 
 become almost unbearable on account of constant 
 backache ; and the symptoms almost assume those 
 of so-called " spinal irritation " in cases where the 
 curvature is but slight. 
 
 Most cases of lateral curvature of the spine, 
 however, do suffer from backache at one period or 
 another. 
 
 A mother notices that a shoulder or a hip is 
 beginning to grow out in a child, often a girl 
 at the onset of puberty. The family doctor is 
 called in; the patient is stripped, and the trunk 
 flexed. If there be no decided or marked irregu- 
 larity in the bent spine, the parent is assured 
 that the patient "will grow out of it," and that 
 nothing special need be done, except, perhaps, 
 
LATERAL CURVATURE OF THE SPINE. 5 
 
 lying down daily for a short time. I have heard 
 this story frequently when examining a case of 
 incurable lateral spinal curvature which had de- 
 veloped in the course of one, two, or more years. 
 It is, however, precisely at the time when there 
 is no osseous deformity, that complete cure is 
 possible. Before lateral curvature can occur with 
 osseous deformity, it must gradually pass through 
 many intermediate stages from the time when 
 the patient first began . to assume a temporary 
 vicious position of the trunk. 
 
 Dr. Oscar Witzel, in Grerhardt's " Handbuch der 
 Kinderkrankheiten," 1887, very ably shows that 
 every pathological form — that is, osseous deformity 
 of the spinal column — is preceded by a pathological 
 posture, in just the same way that the normal 
 osseous form of the spine in the adult is the result 
 of the various postures of the individual during 
 years of growth from infancy. I agree with those 
 who maintain that in lateral curvature of the spine 
 osseous deformity is always preceded by so-called 
 "postural deformity." Some surgeons, however, 
 deny that lateral curvature exists unless associated 
 with osseous deformity of the vertebrae, and speak 
 of "weak spines," which "frequently pass into 
 and become cases of confirmed lateral curvature." 
 However, when once osseous deformity has set 
 in to that extent, the case is now acknowledged 
 to be incurable by leading surgeons ; cases with 
 osseous deformity only differ from one another 
 according to the degree of this deformation. 
 
 I therefore classify all cases of lateral curvature 
 
6 TREATMENT OF 
 
 into two large groups, quite irrespective of their 
 causation, namely, (1) those without any osseous 
 deformity of the ribs or vertebrae, shortly " postural 
 stage;" and (2) those with osseous deformity, 
 "osseous stage," which maybe conveniently sub- 
 divided into (a) slight, (h) moderate, and (c) severe 
 or extreme, according to the degree of the osseous 
 deformity present. 
 
 Every case of lateral curvature, with the excep- 
 tion of those with extreme osseous deformity, 
 causing complete fixation of the vertebrae, presents 
 at least two erect postures : one when the patient 
 is in his habitual position, and the other when 
 placed in the best possible position by the surgeon. 
 Now it appears to me absurd to take careful 
 measurements of the degree of curvature of a 
 patient at the first examination, whilst he is in 
 a comfortable — that is, the habitual — posture, and 
 then a few weeks or months ]ater to take measure- 
 ments again, while the patient may be in the best 
 possible posture temporarily assumed, as appears 
 to be done by some surgeons. Undoubtedly a 
 series of instantaneous photographs, taken ac- 
 cording to my suggestion in the habitual and 
 then in the best possible posture (see photographs 
 1, 2, 3, 4, 5, 6, Case I.), are as good a record as can 
 be obtained for cases of lateral curvature of the 
 first class (postural, or non-osseous deformity, cases), 
 and for subdivision c, or severe cases of the second 
 class (osseous deformity cases). But for cases in 
 subdivisions a and b of the second class, where 
 the osseous deformity is only slight or moderate, 
 
LATERAL CURVATURE OF THE SPINE. 7 
 
 photography is less useful, as it gives no suffi- 
 ciently accurate record of the amount of this 
 bony deformity. Besides, the taking of a series of 
 photographs entails far too much time to be fre- 
 quently employed in active professional practice. 
 
 The following is the method I employ for record- 
 ing cases of lateral curvature of the spine : — 
 
 The patient is placed in front of the surgeon, 
 standing without shoes, with knees extended and 
 feet together, all clothing having been removed 
 to well below the iliac crests, so that the gluteal 
 cleft is just visible. We will suppose that the legs 
 are of equal lengths, or have been made so by a 
 block placed under the shorter limb. Here I may 
 say that surgeons who can draw ever so little will 
 find a rough outline sketch of the patient's back 
 and spine while in the habitual position useful 
 before proceeding further, and that the curve of 
 the spine is more readily recognised if marked 
 with a soft copying-ink pencil (see figs. 10 and 13). 
 After inspecting the patient laterally and in front, 
 the trunk should be flexed as far as possible, the 
 knees being kept extended, and the arms allowed 
 to hang down loosely, so that the scapular muscles 
 are thoroughly relaxed, Now the level of the 
 ribs posteriorly, uncovered by the shoulder-blades, 
 should be carefully examined for any inequality. 
 In the most common form of lateral curvature 
 with dorsal (upper) convexity to the right, if there 
 be any osseous deformity present, the right ribs 
 will be more or less unduly prominent, sometimes 
 so slight that a good light and a well-trained 
 
8 TKEATMENT OF 
 
 tactus eruditus are necessary to make out a differ- 
 ence on the two sides. I now take a tracing of 
 the ribs posteriorly as follows, I feel for the lower 
 angle of the left shoulder-blade, and, fixing one 
 end of a pliable metal tape with my left hand at 
 that point, I carefully mould the tape close to 
 the ribs across the spine, to the lower angle of the 
 right shoulder-blade, which is likewise to be care- 
 fully felt for. With the copying pencil, I mark 
 the metal opposite the dorsal spine, and then 
 carefully remove the tape, upper edge downwards, 
 on to a sheet of quarto-size paper, and draw a 
 tracing inside the tape, marking on the paper the 
 point where the tape crossed the spine. The 
 pencil line is afterwards inked, and the tracing 
 cut out and folded down the middle (see fig. 14), 
 opposite the point marking the spine, and we have 
 now an accurate record of the ribs posteriorly 
 (see fig. 13). 
 
 Similarly, a record is taken of the loins, usually 
 midway on each side between the last ribs and 
 the iliac crests — that is, opposite the third lumbar 
 vertebra — marking the tape, as before, where it 
 crosses the spine (see figs. 12 and 15). 
 
 A little more dexterity is required if the patient 
 is stout or the erectores spinae are bulky, as, if too 
 much pressure is employed in moulding the tape 
 to the contour of the loins, the muscles and soft 
 tissues will cause the tape to spring up when the 
 pressure is removed, and this will vitiate the 
 record. This second outline is then transferred to 
 the paper with the tracing of the ribs posteriorly. 
 
LATERAL CURVATURE OF THE SPINE. 9 
 
 In cases of extreme osseous deformity I have 
 found it advisable to take the tracing of the ribs 
 posteriorly at a higher level — that is, from the top 
 of the left axilla to the corresponding place on the 
 right, including thus a portion of each shoulder- 
 blade, the patient having the trunk thoroughly 
 flexed, as before. In this case I also mark on the 
 metal tape where it touches the inner border of 
 each shoulder-blade, as in the tracing of Case II. 
 (see fig. 11). 
 
 Unless this modification is adopted — that is, 
 taking the tracing from between the axillae instead 
 of from between the lower angles of the shoulder- 
 blades — tracings of the ribs posteriorly in extreme 
 cases are unsatisfactory, too little of the ribs 
 posteriorly being given when the tracing simply 
 extends from the lower angle of one shoulder-blade 
 to that of the other, from more or less increased 
 immovability and displacement of the shoulder- 
 blades, as can be seen in fig. 11, where very little 
 of the right ribs posteriorly would be shown if I 
 had stopped the tracing on reaching the right 
 shoulder-blade. 
 
 Although this method has taken rather long to 
 describe, it enables a surgeon to obtain a correct 
 and reliable record of a case of lateral curvature 
 in less than a minute after a little practice. 
 
 The metal tape I employ is made of pure tin, 
 and is 20 inches long, five-eighths of an inch wide, 
 and about one-twenty-fifth of an inch thick (50 
 centimetres long, 1*5 centimetre wide, and 1 
 millimetre thick), and can be obtained from 
 
10 TEEATMENT OF 
 
 Messrs. Mayer & Meltzer, of London, in a small 
 case to go in the waistcoat pocket. 
 
 Several writers on lateral curvature of the spine 
 have employed a metal tape, but their records are 
 of but little use because the tracings were taken 
 when the patient was erect, when the real amount 
 of osseous deformity is more or less masked by the 
 shoulder-blades as far as the ribs posteriorly are 
 concerned, and by the contraction of the loin 
 muscles with reference to the lumbar vertebras. 
 
 When there is osseous deformity of the ribs 
 anteriorly, especially in cases of pigeon-breast, a 
 tracing can be easily taken from one axilla to the 
 other, either on a level with the nipples or, where 
 the mamma are developed, just below or above 
 them, marking on the tape the position of the 
 nipples and the mid-sternum. In taking this 
 anterior tracing the patient should be placed in 
 the best possible position, with the thorax well 
 thrown forwards ; and he should endeavour to press 
 against the tape whilst it is being moulded to his 
 outline. 
 
 I have employed this method of recording cases 
 of lateral curvature for several years past, and 
 have found it more useful with each year's further 
 experience of it. By its means I have been able 
 to show gradually increasing osseous deformity in 
 cases of lateral curvature due to infantile paralysis 
 of the spinal muscles, than which there are no 
 worse cases to treat, and also in bad cases of 
 lateral curvature after empyema. I have also 
 demonstrated further increase of the osseous 
 
LATERAL CURVATURE OF THE SPINE. H 
 
 deformity where my advice has not been followed, 
 and the patient has come back to me after an 
 interval of months or years. 
 
 I am convinced that if this method of recording 
 cases of lateral curvature were adopted generally, 
 it would be the death-blow of the treatment of 
 such cases by steel, poroplastic, and other supports, 
 except in a few rare cases with more or less 
 complete paralysis of the spinal muscles. These 
 tracings enable surgeons to recognise how the 
 osseous deformity of the ribs and vertebrae gradually 
 progresses from bad to worse in spite of the most 
 complicated and expensive spinal supports. It 
 will be found that the only rational and really 
 successful treatment of lateral curvature, and one 
 which is far more rapid than any other yet offered 
 to the profession, is that which I have the honour 
 to advocate — that is, re-education of the muscular 
 sense of the best possible position, and methodical 
 exercises of the muscles to enable the patient to 
 maintain this improved position without effort, 
 or, to put it more shortly, "treatment by posture 
 and exercise." 
 
 After this careful examination, and before the 
 patient is allowed to dress, it is essential to 
 ascertain to what extent the spine can be restored 
 to its normal position by a voluntary effort, with 
 the help of the surgeon. 
 
 In cases of group (1) — viz., "postural, or non- 
 osseous stage " — where there is no bony deformity 
 of the ribs or vertebrae, this " best possible 
 position " will be perfectly normal, with the 
 
12 TREATMENT OF 
 
 shoulder-blades and hip-bones (iliac crests) sym- 
 metrical, the thorax well thrown out, the abdomen 
 withrawn from undue prominence, and the head 
 erect (see photographs 1, 2, 3, 4, 5, 6, although 
 this case had some osseous deformity). 
 
 In cases of group (2), or " osseous stage," the 
 improvement effected will depend on the amount 
 of bony deformity present. One arm directed and 
 held upwards and the other arm outwards is 
 frequently useful in helping to partially restore 
 the symmetry of the trunks (see photographs 7 
 and 8, which represent a girl, aged seven years, 
 with severe lateral curvature, in the "habitual" 
 posture [photograph 7] and the " best possible " 
 posture [photograph 8]). 
 
 Sometimes the best result is obtained by both 
 arms being raised vertically by the side of the 
 head, while avoiding undue elevation of the 
 shoulder-blades. This best position of the patient's 
 trunk and arms for improving the spine is the 
 " key-note " of the exercises to be practised during 
 treatment. 
 
 A Committee on Lateral Curvature of the Spine, 
 appointed on March 11th, 1887, by the Clinical 
 Society of London, and before whom I demonstrated 
 the same patients both before and after treatment, 
 reported that " The amount of improvement which 
 may be hoped for in any given case may not 
 unsafely be gauged by the improvement which the 
 patient can voluntarily effect {directed or helped by 
 the surgeon) in his or her position tvhen first seen."* 
 * See Clin. Soc. Trans., vol. xxi., 1888, p. 301. 
 
LATEEAL CURVATURE OF THE SPINE. 13 
 
 The importance of placing the patient in the 
 "best possible position" at the first consultation 
 is therefore evident. The patient is only able 
 to maintain this position by a great effort for a 
 few seconds, and she will feel as if she were more 
 crooked than before. The muscular sense has 
 become so perverted that the habitual position 
 appears to her to be far more natural and straighter 
 than the really erect or improved posture. 
 
 It is advisable before concluding the examina- 
 tion to let the patient stand erect, with her 
 back against the door, heels, sacrum, dorsum, 
 and back of head touching it, and with the 
 shoulders well thrown back. While in this 
 position, her mother or friend should try to fasten 
 her stays and clothes in front. In most cases 
 these will not meet for one or more inches, 
 such great alteration and enlargement of the 
 thorax anteriorly being temporarily effected by 
 this simple device. This applies not only to 
 female, but also to male patients, the waistcoat, 
 coat, and overcoat, and frequently even the shirt- 
 collar, not meeting for an inch or more when 
 the patient is placed thus with his back against 
 the door. Finally, the stockings being removed, 
 notice should be taken whether the patient is 
 flat-footed or not. One out of every three cases 
 of lateral curvature of the spine has marked flat- 
 foot (see Appendix). 
 
 Treatment. — Common-sense suggests that any 
 inequality in the potential or practical lengths of 
 the lower extremities is to be corrected by wearing 
 
14 TREATMENT OF 
 
 a thicker sole on the shorter leg, whatever other 
 treatment may appear to be indicated. 
 
 Of late years the implicit faith formerly placed 
 in the treatment of lateral curvature of the spine 
 by steel and other spinal supports or stays has 
 been gradually undermined, and even those who 
 still adhere to the mechanical treatment of spinal 
 deformities not due to diseased bone attach more 
 and more importance to its association with suit- 
 ably prescribed gymnastics. Lateral and other 
 curvatures due to paralysis of the spinal muscles, 
 when the patient is unable by a voluntary effort 
 to maintain himself in an improved position for 
 even a few seconds, are the only cases in which 
 spinal supports may be of some use. In these 
 paralysed backs, attempts should be made to pre- 
 vent further in crease of the osseous deformity; and 
 in some cases this is possible by the application 
 of a well-made Bauer posterior spinal support, 
 which is fixed by means of a strong leather pelvic 
 band and shoulder straps. This support may be 
 worn till the muscles have sufficiently recovered 
 from their paralysis to enable the patient to hold 
 the spine in an improved position even for a few 
 seconds. It is understood that this support is 
 worn with the sole idea of being preventative, and 
 not of being curative, and should be left off at 
 night in bed. 
 
 Lying on the back for several hours daily, still 
 almost universally prescribed by orthopaedic and 
 other surgeons, is perfectly useless as far as cure 
 of the lateral curvature is concerned. If a limb 
 
LATEEAL CURVATURE OF THE SPINE. 15 
 
 with weak and flabby muscles were put into stiff 
 sprints and kept at rest for several hours daily, the 
 muscles would surely become still weaker; and 
 this is equally true of the spinal muscles. The 
 patient may lie on the back or face for fifteen or 
 thirty minutes at a time for the relief of pain or 
 when fatigued by exercise; but lying for longer 
 periods does far more harm than good. 
 
 The treatment I advocate is based upon prin- 
 ciples which may be taken under the following 
 heads : — 
 
 (a) Ee-education of the patient's muscular sense 
 as to an erect or improved position. 
 
 (b) Improved position to be maintained at all 
 times, while sitting or standing. 
 
 (c) Attention to dress. 
 
 (d) Systematic training of the spinal and other 
 muscles, including the development of the thorax. 
 
 (e) Attention to general health. 
 
 (/) Subsequent home treatment to prevent re- 
 lapse in the improvement or cure that has been 
 obtained by the surgeon. 
 
 (a) He-education of the patient's muscular sense 
 as to an erect or improved position. — A patient 
 with confirmed lateral spinal curvature is so 
 habituated to the crooked position that consider- 
 able patience and perseverance is required to 
 convince him or her that an erect or improved 
 posture is really such, and not an exaggeration of 
 the deformity. The best way of commencing this 
 re-education is for the patient to lie on the back 
 in the best possible position, and while thus to 
 
16 TREATMENT OF 
 
 practise slow breathing, the shoulders being kept 
 well pressed back. All the simple movements of 
 the head (neck), arms, and legs can be practised in 
 this position. A hand looking-glass as well as an 
 ordinary wall mirror are very useful, so that the 
 patient may see and be convinced of the improved 
 position. This re-education of the muscular sense 
 for the improved or normal posture is to be kept 
 in mind throughout the whole treatment. 
 
 (b) Improved position to be maintained at all 
 times, ivhile sitting or standing. — This best possible 
 posture is always to be maintained while sitting, 
 whatever the occupation of the moment may be : 
 at meals, at the piano, while reading, writing, etc. 
 It is most readily obtained by sitting with the 
 sacrum, loins, dorsum, and shoulders well supported 
 against the back of the chair, which should be 
 moulded to the normal shape of the spine, with a 
 slight prominence to fill the hollow of the loins. 
 Almost any ordinary chair can be made to answer 
 the purpose, if a suitable cushion is used. In 
 writing, the patient's trunk is required to be more 
 vertical than for reading ; and it is essential that 
 not only the trunk, but the arms, should remain 
 perfectly symmetrical. A sloping desk is abso- 
 lutely required ; and the paper should be placed 
 obliquely upwards from left to right, but exactly 
 in front of the patient. The Glendenning adjust- 
 able modern school desk and seat, manufactured 
 by the North of England School Furnishing Co., 
 Darlington, will be found most beneficial for 
 patients of school age, and even for many adults 
 
LATERAL CURVATURE OF THE SPINE. 
 
 17 
 
 (see figs. 2, 4, 5, 6). In reading, an inclined back 
 to the chair is more restful to weaker patients, 
 
 Fig. 6. 
 
 \s& 
 
 
 Explanation. — By the application of 
 a key to A and B, the desk and seat 
 may be raised or lowered to any de- 
 sired height. 
 
 Desk top slides horizontally. 
 
 Writing slope at 15°, reading at 40°. 
 
 especially adults ; and an easel table should support 
 the book (see fig. 7). For music the same rules 
 
 2 
 
18 
 
 TREATMENT OF 
 
 apply, the ordinary music-stool being discarded 
 and a high-backed chair employed, which will 
 
 Fig. 7. 
 
 Fig. 8 
 
 Fi°\ 9. 
 
 PRACTISING. 
 
 Position on ordinary music- 
 stool. 
 
 Position on Glendenning's 
 Patent Music Chair. 
 
 also come in useful for meals (see fig. 9, which 
 represents a good music-stool with back, also 
 
LATERAL CURVATURE OF THE SPINE. 19 
 
 manufactured by the North of England School 
 Furnishing Co., Limited). In all cases, the seat of 
 the chair or couch should be horizontal, and not 
 tilted up in front, as is frequently seen in so-called 
 spinal couches ; and the patient's feet should always 
 be supported, either by the ground or by a foot- 
 stool. The thighs should never be crossed, as this 
 throws the spine as much on one side as does 
 standing on one leg. 
 
 When we find an able surgeon not only advo- 
 cating shoulder-braces, but even inventing a new 
 one, still more injurious than most of its prede- 
 cessors, because of its greater strength from being 
 manufactured of solid rubber bandage,* one feels 
 inclined to rub one's eyes and to ask whether 
 scientific orthopaedic surgery is really advancing or 
 whether we have gone back half a century or more. 
 
 John Shaw, that enlightened and able author 
 of a more rational treatment of lateral curvature, 
 criticised shoulder-straps as follows : f " The effect 
 which this instrument (shoulder-brace or ' common 
 back-collar ') produces in ordinary cases may be 
 easily comprehended. ... If the shoulder-blades 
 be brought close to the spine by the straps of the 
 brace and kept constantly so, there can be no use 
 for the several strong muscles which pass from the 
 spine to the shoulder-blades. They must conse- 
 
 * See the Lancet, May 3rd, 1884: "On a New Form of 
 Shoulder- brace for the Treatment of Stooping Habits, Incipient 
 Lateral Curvature, etc " 
 
 t " Further Observations on the Lateral or Serpentine Curvature 
 of the Spine. . . . Being a Supplement to the Work on Distortions 
 of the Spine and Bones of the Chest." London : 1825. 
 
20 TKEATMENT OF 
 
 quently waste and become nearly useless, while 
 those on- the forepart of the chest, being excited 
 to resist the straps, will become increased in power; 
 and hence, when the brace is taken off, not only 
 will the shoulders fall forward, as in a delicate 
 person, but the muscles on the forepart of the 
 chest will predominate over those by which the 
 shoulder-blades should be held back and pull the 
 shoulders forward." 
 
 This was written upward of sixty years ago, 
 and is so complete and simple a refutation of any 
 supposed efficacy of shoulder-straps for stooping 
 habits that I have little to add to John Shaw's 
 scientific common-sense. 
 
 I have observed in numerous instances where 
 shoulder-braces have been worn for several months 
 or longer, and where, from misplaced perseverance 
 and severity, they have been worn extra tightly, 
 that the unfortunate wearer has tried to obtain 
 relief from the excessive pressure of the straps 
 over the coracoid process and adjacent clavicle on 
 each side, by throwing the whole upper trunk back- 
 ward by undue arching of the loins, with the result 
 of producing severe lumbar lordosis in addition to 
 the dorsal kyphosis for wnich the apparatus was 
 being worn. I am quite aware that dorsal kyphosis 
 is generally accompanied by compensatory lumbar 
 lordosis, but in these cases to which I refer the 
 lumbar hollow is much severer than usual and 
 causes an exaggerated thrusting forward and pro- 
 minence of the abdomen. Of course I am referring 
 to the kyphosis of muscular debility, and not to that 
 
LATERAL CURVATURE OF THE SPINE. 21 
 
 due to spinal caries. In spite of these facts, many 
 medical men of the present day are in the habit 
 not only of allowing, but even of advising, patients 
 to wear these instruments of torture. 
 
 The only way in which shoulder-straps might 
 be worn with benefit — not that I ever recommend 
 them — is well illustrated by the following anecdote, 
 which is also culled from good old John Shaw : An 
 eminent surgeon was consulted by a gentleman 
 who became one of our first tragedians as to the 
 best mode of correcting a stoop which he had 
 acquired. The surgeon told him that neither 
 stays nor straps would do him any essential good, 
 and that the only method of succeeding was to 
 recollect to keep his shoulders braced back by a 
 voluntary effort. But the tragedian replied that 
 this he could not do, as his mind was otherwise 
 occupied. The surgeon then told him that he 
 could give him no further assistance. Shortly 
 after this conversation the actor ordered his tailor 
 to make a coat of the finest kerseymere, so as to fit 
 him very tightly when his shoulders were thrown 
 back. Whenever his shoulders fell forward, he 
 was reminded by a pinch under the arms that his 
 coat cost him six guineas, and that it was made 
 of very fragile materials ; being thus forced, for 
 the sake of his fine coat, to keep his shoulders back, 
 he soon cured himself of the stoop. He then 
 showed himself again to tbe surgeon, who ever 
 afterward, when consulted whether young ladies 
 should wear shoulder-straps, permitted them on 
 condition that they were made of fine muslin or 
 
22 TREATMENT OF 
 
 valuable silk, for tearing which there should be a 
 forfeit ! 
 
 I am totally opposed therefore to all mechanical 
 contrivances for trying to fix the patient in 
 an improved posture while writing, reading, 
 etc., whether by means of braces, stays, or 
 head — or rather forehead — rests, which last have 
 been strongly advocated by several Continental 
 surgeons. My results, which are far more rapid 
 and so much more successful than those obtained 
 by other methods of treatment, are won by the re- 
 education of the patient's muscular sense for the 
 improved or normal posture without the employ- 
 ment of any mechanical restraint. 
 
 Short sight or any other deficiency of the eyes 
 must be at once attended to, by suitable spectacles, 
 etc., as it would be useless to urge a patient to hold 
 herself erect who had always to poke the head 
 forward for reading or looking at anything. 
 
 Standing still should be avoided at all times ; 
 when inevitable, the patient ought to stand equally 
 on both legs with the feet a few inches apart. 
 Standing on one leg is most injurious, as it at once 
 throws the spine into a serpentine position, in- 
 creasing the lateral curvature. 
 
 A horsehair mattress with a low pillow is all 
 that need be advised for the night. 
 
 (c) Attention to dress. — It is essential that no 
 article of clothing should interfere with the re- 
 sumption of an improved or perfectly normal 
 position of the patient's spine and trunk. This 
 can be tested by making the patient stand with 
 
LATERAL CURVATURE OF THE SPINE. 23 
 
 the back to the wall and with the clothes opened in 
 front, as already mentioned (see p. 13). In girls 
 up to puberty, and even later, three articles of 
 dress are generally sufficient, viz., a pure wool 
 combination next the skin, thick for winter, thin for 
 summer, a petticoat or divided skirt with bodice 
 attached, all of wool, and an outer dress. An 
 extra petticoat may be worn in very cold weather. 
 In women there should be no red zone of pressure 
 on the skin of the thorax or abdomen produced 
 by stays or injudiciously placed tight petticoat 
 bands ; the latter should be shaped and made to 
 fit round the pelvis, so as not to compress the 
 lower ribs above the hip bones (iliac crests). Stays 
 with very little whalebone or steel, and with a 
 vertical slip of elastic webbing, expanding trans- 
 versely, inserted on each side, are advised when- 
 ever the breasts are at all developed. Such stays 
 admit of the full expansion of the lower ribs, and 
 are worn, not with the object of supporting the 
 spine, but for steadying the mammae and keeping 
 the outer dress neat and without folds. 
 
 (d) Systematic training of the spinal and other 
 muscles, including the development of the thorax. — 
 At first, attention is to be directed to correcting 
 the antero-posterior curves of the spine ; when 
 these are improved, then only is it possible to 
 carry out special exercises for correcting the lateral 
 curves. 
 
 The following is a prescription of twelve exer- 
 cises with which I always commence the treatment 
 of cases of lateral curvature of the spine. The 
 
24 TREATMENT OP 
 
 patient should rest for a minute or two between 
 each exercise on a couch with movable back fixed 
 at an angle of 45° (see fig. 7), or an ordinary chair 
 properly arranged : — 
 
 1. Lying on back ; arms by the sides of the 
 body ; palms upwards ; slow, deep inspiration by 
 the nose ; slow expiration by the mouth. (Re- 
 peated four times.) 
 
 2. Similar exercise with the arms extended 
 upwards by the sides of the head. (Repeated 
 four times. 
 
 3. Same position as (1) ; head-rotation on 
 axis to right and left alternately ; also lateral 
 flexion of head to right and left alternately. 
 (Repeated four times.) 
 
 4. Lying on back ; simultaneous circumduction 
 of both shoulder-joints from before backwards; 
 elbows and wrists kept extended. (Repeated 
 twelve times.) 
 
 5. Lying on back ; one hip circumduction both 
 ways ; knee kept extended. (Repeated ten 
 times.) 
 
 6. Lying on back ; simultaneous extension of 
 arms upwards, outwards, and downwards, from a 
 position with the elbows flexed and close to the 
 trunk. (Repeated four times.) 
 
 7. Lying forwards ; one hip circumduction 
 both ways ; knee kept extended. (Repeated ten 
 times.) 
 
 8. Sitting on couch, with back at an angle of 
 45° ; ankle circumduction down, in, up, and out, 
 while the toes are directed inwards the whole 
 
LATERAL CURVATURE OF THE SPINE. 25 
 
 time. (Eepeated twenty times.) Also foot adduc- 
 tion, patient resisting ; abduction, surgeon resist- 
 ing. (Eepeated eight times.) (For flat-foot.) 
 
 9. Lying on back, with arms extended upwards 
 by the sides of the head ; flexion of both arms, 
 surgeon resisting by grasping the hands, followed 
 by extension, patient resisting. (Repeated six to 
 •eight times.) (The patient's knees, flexed over 
 the end of the table, fix his trunk.) 
 
 10. Patient astride a narrow table or chair 
 without back, with arms down and hands supinated; 
 trunk flexion at lumbar vertebrae, patient resisting 
 slightly, followed by trunk extension, surgeon 
 resisting by his hand against back of patient's 
 head. (Eepeated six to eight times.) 
 
 11. Patient, with arms extended upwards, stands 
 with head, back, and heels against a vertical 
 post with pegs on each side, which he grasps. 
 The surgeon gently pulls the patient's pelvis for- 
 wards by his hands on the sacrum, patient resist- 
 ing ; and then the patient moves back the pelvis 
 to the post, surgeon resisting. At no time are the 
 patient's heels to be raised from the floor. Also 
 pelvis rotation on its axis to right and left alter- 
 nately, surgeon resisting with his hands on each 
 side of the pelvis. (Eepeated six to eight times.) 
 
 12. Lying on back, with head and neck pro 
 jecting beyond the end of the table ; arms by the 
 side of the body, palms up ; the head is gently 
 flexed by the surgeon's hand on the occiput, patient 
 resisting, followed by head extension, surgeon re- 
 sisting. (Eepeated eight times.) 
 
26 TREATMENT OF 
 
 The last four exercises are personally carried out 
 by the surgeon, while trained female assistants do 
 the remaining eight under his supervision. 
 
 It is important, while practising this prescription 
 of exercises, that respiration should not be inter- 
 fered with by involuntary fixation of the chest 
 walls. The patient should therefore always count 
 aloud (e.g. j 1 to 5 or 10) during the execution of all 
 exercises, except those of breathing. Six to twelve 
 firm longitudinal " strokings," from above down, 
 of the patient's back by the assistant's palms, 
 generally remove any aching caused by the exer- 
 cises. These strokings are also usefully employed 
 at home to relieve backache. The exercises should 
 be done slowly, and great care taken that the head 
 and trunk remain the whole time in the best posi- 
 tion. This prescription requires three-quarters to 
 one hour's time to go through, and should be fol- 
 lowed, if the patient is at all tired, by a short rest 
 in a good position, with the back supported. 
 
 The prescription is repeated daily ; and as the 
 patient gradually gains more power and begins to 
 assume the improved position more readily and 
 with less exertion, other and more severe exercises 
 are gradually added. In a day or two, if the 
 patient is not overfatigued, the following standing 
 exercise is done : The patient, with the feet 
 slightly apart and the heels fixed against a ledge 
 or wall, rests with the front of the thighs against 
 a low padded horizontal bar, while holding herself 
 as erect as possible ; the surgeon then gently 
 flexes the patient's trunk by pressing his hand 
 
LATERAL CURVATURE OF THE SPINE. 27 
 
 against the back of her head, patient resisting ; 
 and then the patient slowly recovers the vertical 
 position against the surgeon's resistance, this 
 being, in fact, exercise (10) described above, in a 
 standing instead of a sitting posture. In about 
 three weeks or a month, the following much more 
 severe exercise can be tried, known as " Forwards 
 lying, heels fixed, trunk extension and flexion,' 1 
 carried out as follows : The patient lies prone, 
 with the pelvis and legs supported and the heels 
 fixed (the latter best by some one sitting on them) 
 on a padded table, while the head and trunk to the 
 level of the iliac crests project beyond the edge of 
 the table. The patient slowly raises the trunk 
 into the same horizontal position as the legs and 
 pelvis, and slightly higher, and then as slowly 
 allows the trunk to be again flexed by its own 
 weight. The surgeon easily increases the severity 
 of the exercise, if required, by more or less pressure 
 w r ith one hand at the back of the patient's head. 
 During this exercise, the arms may be in any 
 position required. By the time the patient is able 
 to perform this exercise without pain, the antero- 
 posterior curves will be sufficiently improved ; and 
 more attention can be paid to her being exercised 
 in the " key-note " position — i.e., that position of 
 the trunk and arms in which the greatest improve- 
 ment in the position of the spine is obtained (see 
 p. 12). Another severe exercise which can also 
 be practised now is shortly described as " Long 
 sitting, trunk extension and flexion." Here the 
 patient sits on a table, with the legs together and 
 
28 TREATMENT OF 
 
 the knees extended ; an assistant sits on the 
 legs below the knees, to fix them ; the patient 
 slowly extends the spine against the surgeon's 
 resistance (applied by his hand against the 
 back of the patient's head or back) till the 
 trunk is in the same horizontal plane as the legs ; 
 the patient then slowly and gently resists, while 
 the surgeon raises her into a vertical position of 
 the trunk. 
 
 Female patients usually continue the daily 
 repetition of these exercises during the menses, 
 except that the hip circumductions are omitted for 
 three or four days, as these movements tend to 
 increase the menstrual flow. Where menorrhagia 
 or dysmenorrhoea is present, it is sometimes 
 necessary to leave off the exercises altogether for 
 a day or two. As a general rule, it is better to 
 accustom the patient to practise most of the 
 exercises all through the period of menstruation. 
 While on the subject it may be stated that flexions 
 of the uterus are no hindrance to the treatment, 
 as none of the exercises described are violent or 
 jerky in their execution; and, from the fact that 
 respiration is never allowed to be impeded by the 
 previously mentioned simple device of making the 
 patient constantly count aloud, any over-exertion 
 can always be prevented with ordinary care. I 
 have several times given a three months' course 
 of treatment with the usual beneficial result even 
 while a pessary has been worn, and this with the 
 permission of the gynecologist. The patient's 
 spine should be examined again at the end of 
 
LATERAL CURVATURE OF THE SPINE. 29 
 
 three or four weeks, to observe how it is affected 
 by the treatment and whether any alteration of 
 details is required. 
 
 In cases of "non-osseous," or "postural," lateral 
 curvature, one or two months' daily perseverance 
 in the treatment will effect a cure of the de- 
 formity ; while in cases with " osseous " deformity 
 three months' daily treatment will, on an average, 
 effect all the improvement that is possible, viz., a 
 strong and straight er back, with arrest in the 
 further increase of the deformity of the ribs and 
 vertebrae. Some very severe cases, especially those 
 associated with much pain, require as long a 
 treatment as six months ; but this is exceptional. 
 The great advantage of this treatment of lateral 
 curvature over that by spinal supports and lying 
 down for many hours daily is that it always 
 tends to improve the general health of the patient,, 
 notably in delicate, anaemic, and badly nourished 
 girls at the onset of puberty. 
 
 (e) Attention to general health.- — Care should 
 be taken to improve the general health in every 
 possible way. If the appetite is poor, a good basin 
 of bread-and-milk or oatmeal porridge and milk 
 should be ordered for breakfast, and patients made 
 to persevere, even if they complain of discomfort 
 at first. This especially applies to young ladies 
 who have been in the habit of taking only half a 
 slice of dry toast and a cup of tea or something 
 similar for breakfast. In emaciated patients the 
 true weight should be obtained by deducting the 
 weight of the clothes after weighing ; an increase 
 
130 TREATMENT OF 
 
 of from one half to two or three pounds is generally 
 obtained after one month's treatment. 
 
 Patients with constant wearying backache, 
 generally in the loin muscles, especially at night, 
 are much relieved by a simple water compress, 
 applied as follows : A soft towel or handkerchief, 
 folded into an oblong about eight inches by six, is 
 dipped into warm water, squeezed moderately dry, 
 and placed over the painful spot. This is kept 
 in position by a thicker dry towel folded longi- 
 tudinally, which should be sufficiently wide to 
 overlap the wet compress by at least an inch 
 above and below, and fastened in front of the 
 thorax by tapes or safety pins ; no oil-silk should 
 be used. Some patients prefer the compress 
 applied cold ; but this matters little, as it soon 
 assumes the temperature of the body. When the 
 pain is distinctly localised, as below one scapula 
 or over one or several vertebral spinous processes, 
 I have found the employment of an acupuncture 
 instrument, such as Dr. Brindley James's, fre- 
 quently useful in effecting an immediate and some- 
 times a permanent cure of the neuralgia. A daily 
 morning bath with cold or tepid water, if the 
 patient's powers of reaction are low, is a good 
 general tonic. Singing, by helping to develop 
 the thorax, is useful. At least one and a half to 
 two hours' daily walking out of doors is to be in- 
 sisted on ; running and joining in games, especially 
 lawn tennis, are beneficial after a time, provided 
 any fatigue thus induced disappears after resting 
 for a quarter or half an hour ; any walk or exercise 
 
LATERAL CURVATURE OF THE SPINE. 31 
 
 that induces fatigue or pain lasting hours only 
 does harm. In such cases, the duration of the 
 walk, etc., must be curtailed. 
 
 (/) Subsequent home treatment to prevent 
 relapse in the improvement or cure that has been 
 obtained by the surgeon. — To keep up the im- 
 provement and to prevent any relapse in a cured 
 case, it is important to continue to enlist the 
 patient's co-operation and interest in his or her 
 own case on ceasing treatment ; and for the last 
 ten years I have been in the habit of giving 
 patients on leaving a written home prescription of 
 movements, of which the following is an average 
 example. 
 
 Final home prescription of exercises: — 
 
 1. Lying on back; arms by sides; palms upwards; 
 slow, full inspiration by the nose ; slow expiration 
 by the mouth (four times). 
 
 2. Sitting astride a chair, with the arms directed 
 upwards by the sides of the head and holding a 
 stick (or as in 1) ; trunk lumbar flexion and exten- 
 sion ; also trunk rotation on its axis right and 
 left (six times). 
 
 3. Same position as (1) ; head-rotation on axis to 
 right and left ; also hea-d lateral flexion to right 
 and left (four times). 
 
 4. Lying prone on ground ; heels fixed by pres- 
 sure on them ; arms as in (2) ; trunk-raising 
 (extension) and flexion ; also trunk rotation on its 
 axis right and left (six times). 
 
 5. Same position as (1) ; one hip circumduction 
 both wa3 r s ; knee kept extended (ten times) (a shot 
 
32 TREATMENT OF 
 
 weight of five to ten pounds is attached to the 
 foot to increase the severity of the exercise) . 
 
 6. Lying on back ; slow simultaneous cir- 
 cumduction of both shoulder-joints from before 
 backwards ; elbows and wrists extended (twelve 
 times). 
 
 7. Lying prone on ground ; heels fixed by pres- 
 sure ; trunk kept raised from ground (extended) ; 
 simultaneous extension of the arms upwards, out- 
 wards, and downwards from a position of elbows 
 flexed and close to the trunk (four times). 
 
 8. Standing with back against door, arms 
 directed upwards, and hands grasping two pegs 
 fixed into the door ; pelvis rotation on vertical 
 axis right and left (ten times) ; also the same 
 hanging with the feet raised off the ground and 
 sacrum kept touching the door (four times). 
 
 9. Lying prone ; one hip circumduction both 
 ways ; knee kept extended (a bag of shot, weight 
 of five to ten pounds, is attached to the foot to 
 increase the severity of the exercise). 
 
 10. Walking forwards and backwards with the 
 arms directed upwards by the sides of the head 
 and holding a stick, or arms by sides ; palms 
 directed forwards (a hundred steps). 
 
 This " home prescription " is practised for half 
 an hour twice a day for six months, and then once 
 a day for another six months. At the end of the 
 twelve months I examine the patient ; and if the 
 improvement or cure previously effected shows no 
 relapse, I give permission to leave off all special 
 treatment. In all cases it is absolutely necessary 
 
LATERAL CURVATURE OF THE SPINE. 33 
 
 to persevere in the maintenance of good positions 
 for some years, 
 
 During the treatment horse exercise is not 
 advised, at least not for the first year ; afterwards 
 it is permitted, but female patients should use a 
 reversible saddle, and learn to ride alternately on 
 the " near " and '•' off " side. 
 
 The following three cases are illustrative of the 
 treatment described above. Case I. was exhibited 
 before the Clinical Society of London on April 13th, 
 1883 (see Clin. Soc. Trans., vol. xvi., 1883) :— 
 
 Case I. — Miss ■, set. eighteen, a student at 
 
 one of the London academies of music, was 
 brought to me on March 4th, 1882, with the 
 following history : Three paternal aunts had 
 spinal curvature, one much deformed ; the patient 
 is one of sixteen children, of whom ten are living. 
 Two younger sisters, aged sixteen and fourteen 
 years respectively, stoop considerably, but have 
 no lateral curvature. Up to fourteen years old 
 (four years ago) the patient was strong, and never 
 complained of her back. She then began to stoop 
 and have backache, especially after long walks ; 
 the pain in the back would last till she went to 
 bed. There was no illness or rapid growth to 
 account for this weakness of the spine. The 
 backache gradually became worse ; and three years 
 ago the patient was examined by one of the 
 surgeons of the Sussex County Hospital, who said 
 the spine was not straight ; and she was ordered 
 to lie down for two hours daily and to eat slowly. 
 At the end of another year, the same surgeon 1 
 
 3 
 
34 TREATMENT OF 
 
 found the spine decidedly worse, so an ordinary 
 steel spinal support, with pelvic band and shoulder 
 crutches, was ordered of Pratt. This instrument 
 has been worn for two years up to a month ago, 
 the mother assuring me that her daughter had 
 become worse both in her figure and the backache 
 during that time. 
 
 On examination, I found the patient rather thin 
 and the subject of lateral curvature, the whole 
 spine being convex laterally to the left, the right 
 scapula being more than two inches below the 
 level of the left one; also considerable exaggeration 
 of the cervico-dorsal antero-posterior convexity, 
 causing poking of the head, much flatness of the 
 thorax anteriorly, and even undue prominence of 
 the abdomen, although she was so thin. I found 
 a slight amount of permanent rotation to the left 
 of the lumbar vertebrae, and a slight increase of the 
 convexity of the left ribs posteriorly as compared 
 with the right side when the patient's spine was 
 flexed. Although the patient looked so deformed, 
 she could be placed in an almost normal position, 
 and maintain that position by a great voluntary 
 effort for a few seconds. Her feet and knees were 
 normal. Sitting for half an hour any time of the 
 day would bring on severe backache. I was inter- 
 ested to hear that whenever she wished to sing 
 extra well she left off the spinal support for the 
 occasion. Her dress and stays were much too 
 tight round the thorax, so that scarcely any 
 inspiratory movement took place in the lower half 
 of the thorax. 
 
LATERAL CURVATURE OF THE SPINE. 35 
 
 I gave her directions about position and a few 
 simple exercises for developing the thorax, includ- 
 ing systematic deep breathing, to be practised for 
 fifteen to twenty minutes twice daily. I ordered 
 the spinal support to be given up. 
 
 Nine months later — viz., on Dec. 18th — I saw 
 the patient for the second time. Both she and 
 her mother considered there was a decided im- 
 provement, notwithstanding severe backache for 
 the last fortnight. The prescribed exercises have 
 been on an average practised four times a week. 
 Her professor of singing has complained of her 
 want of "breath." On examining the spine, I 
 found it in the same state as when I saw the 
 patient the previous and first time. 
 
 Two days later — Dec. 20th — six photographs 
 -were taken, which speak for themselves (see photo- 
 graphs 1 to 6). Photographs 1, 2, 3, are the three 
 views, posterior, lateral, and anterior, of the patient 
 in her habitual position ; and photographs 4, 5, 6, 
 are the corresponding three views of the patient 
 in the best possible position in which I could place 
 her. In all six photographs she was standing 
 without boots, with the feet close together and 
 the knees fully extended, while the pelvis was 
 placed symmetrically in relation to the feet. 
 These photographs were taken by a quick process, 
 yet it cost her considerable effort and backache 
 to maintain the improved position in which I 
 placed her for the few seconds necessary. 
 
 My prognosis was that the patient could be so 
 strengthened by three months' daily treatment, 
 
36 TREATMENT OF 
 
 that this temporary improved position, involving 
 such great effort when the photographs were taken, 
 would become a permanent one without any effort, 
 at the same time that all pain would disappear — 
 that is, practically a complete cure, although a 
 slight permanent rotation of the lumbar vertebrae 
 would be left. 
 
 On Dec. 23rd the patient began daily treat- 
 ment, visiting my house for three-quarters to one 
 hour daily. The following are extracts from my 
 notebook: — 
 
 " Jan. 15th, 1883, seventeenth visit for treatment. 
 — For the last week the patient has been doing two 
 or three exercises while the right arm is directed 
 vertically upwards and the left outwards from the 
 side of the trunk. Yesterday and the day before 
 she was Without backache the whole day. This 
 is the first time for more than two years that there 
 has been a day altogether without backache. The 
 patient's professor of singing saw her to-day, and, 
 without anything being said to him, at once 
 observed the marked improvement in her figure, 
 and on trying her voice, found there was an 
 increased power of 'breathing.' 
 
 " Jan. 16th. — The patient tells me the dressmaker 
 has had to let out her dress more than five inches 
 across the chest. On examining the back, I found 
 the habitual position decidedly less deformed than 
 it was on Dec. 20th, less than a month ago. Her 
 mother and friends noticed a decided improvement 
 in her figure at home. Her appetite is much- 
 better, especially at breakfast. 
 
LATERAL CURVATURE OF THE SPINE. 37 
 
 " Jan. 31st. — The patient has had no backache 
 since Saturday, viz., three clear days. 
 
 "Feb. 23rd. — The patient has not had any back- 
 ache since Wednesday week, viz., ten days ; 
 previously she had rather severe backache for two 
 or three days ; during these last ten days she has 
 been up to London and back four or five times, 
 attending the Academy of Music. 
 
 " April 9th. — On examination Ifound the habitual 
 position very much improved, scarcely any differ- 
 ence in the level of the shoulder-blades, and the 
 antero-posterior spinal curves almost normal. The 
 patient assumes the best possible position with 
 great ease ; the erectores spinse muscles are now 
 highly developed. When the spine is flexed, the 
 left erector spinge muscle is still too prominent. 
 The whole trunk is vastly more symmetrical in the 
 babitual position — that is, the one assumed without 
 extra muscular effort. 
 
 11 April 11th (Wednesday). — The patient is still 
 without backache. If this lasts till to-morrow 
 (Saturday), that will be four clear weeks passed 
 without aching in the back. 
 
 " The patient is so much improved in figure 
 and strength, that she is to cease treatment 
 shortly." 
 
 [" The young lady, the subject of the lateral 
 curvature, was exhibited, and went through the 
 various phases of the 'medical gymnastics' which 
 had been practised with the view of bringing about 
 a cure. The muscles, when in action in the 
 different movements, came out very strongly. The 
 
38 TREATMENT OF 
 
 case seemed to have undergone marked improve- 
 ment." — Medical Times and Gazette, April 21st, 
 1883.] 
 
 This young lady two years afterwards went on 
 the stage of one of the leading theatres in London, 
 and has continued to act up to the present time. 
 
 When the Clinical Society's Committee on 
 Lateral Curvature of the Spine was appointed on 
 March 11th, 1887, nearly the first letter I received 
 from the Hon. Secretary was one requesting me to 
 exhibit this patient before the Committee. The 
 young lady most kindly consented, and she was 
 thoroughly examined by all the members of the 
 Committee on April 15th, 1887. She also informed 
 the Committee that the dressmaker of the theatre 
 had never found fault with her figure when trying 
 on new dresses. I believe I am correct in stating 
 that the Committee were satisfied that there had 
 been no relapse since the patient had been exhibited 
 at the Clinical Society's meeting four years pre- 
 viously. This was a severe test of the permanence 
 of the cure I had been able to effect, because this 
 young lady at the time she saw the Committee 
 at my house was not only acting every night in 
 two pieces, but was rehearsing for several hours 
 daily in a new play, which was soon afterwards 
 successfully placed on the stage. 
 
 Case II. — Miss E. L., set. seventeen years, from 
 Jersey, consulted me on April 24th, 1888, with the 
 following history : About eight years ago "the right 
 shoulder was observed to be growing out," the only 
 ascertainable cause being a very rapid growth. The 
 
LATERAL CURVATURE OF THE SPINE. 
 
 39 
 
 family doctor on being consulted advised nothing 
 being done, as "it would all pass away." Four 
 years ago, the patient in the meanwhile having 
 become more deformed, a steel spinal support was 
 applied and worn for six months ; this was then 
 replaced by a series of four Sayre's plaster-of-Paris 
 jackets, applied at intervals of three months ; then 
 
 Fie. 10. 
 
 Rough sketch of back of Case IT., 
 with extreme lateral curvature (habitual 
 posture). 
 
 a poroplastic spinal support was applied, and had 
 been worn for two years up to the time of consulting 
 me. In spite of the continuous mechanical treat- 
 ment of the last four years, the young lady had 
 become terribly deformed, as can be easily seen 
 from the rough sketch of the back (fig. 10), and 
 from the reduced copies of the tracings of the ribs 
 posteriorly (fig. 11) and of the loins (fig. 12), which 
 
40 TREATMENT OF 
 
 I took according to the method already described. 
 
 These show the extreme deformity of the right ribs 
 behind, and the serious prominence of the left 
 
LATERAL CURVATURE OP THE 8PINE, 41 
 
 hip-bone. The ribs anteriorly are likewise much 
 deformed, and the whole thorax is consequently 
 most unsymmetrical. 
 
 When the patient was placed in the best possiblo 
 posture, with the back against the door, her stays, 
 dress, and jacket would not meet in front for three 
 or four inches. Her general health at the time 
 of the consultation was only " pretty " good, and 
 the patient complained of frequent pain in the 
 back and beneath the left shoulder-blade. 
 
 1 gave as my prognosis that three months' daily 
 
 Fig. 12. 
 
 Tracing of: loins midway from ribs to iliac crests in flexed 
 position of trunk, in same patient as Pigs. 10 and 11 (half 
 natural size). 
 
 treatment would effect all that could be done in 
 such a bad case, viz., a slight improvement in the 
 spine, a better figure, a much stronger back, and a 
 marked improvement in the general health, and 
 at the same time an arrest of further increase in 
 the osseous deformity of the ribs and vertebra;. 
 The patient came under my care a day or two 
 afterwards, the spinal support being of course 
 left off altogether ; and the following notes of the 
 progress of the patient are taken from my case- 
 book : — 
 
 " May 15th. Eighteenth visit for treatment. — The 
 
42 
 
 TREATMENT OF 
 
 patient began to- clay the severest exercises ; she 
 is doing extremely well. 
 
 " May 30th. Twenty-ninth visit for treatment ; 
 examined ; ' key-note ' is a position of ' left arm 
 directed upwards, right arm directed outwards.' 
 There is slightly more movement in the spine > 
 
 Fie. 13. 
 
 Miss MB. cet. 1G years 
 Jpril2]-mfi 
 
 Rough sketch of back of Case III., 
 with severe lateral curvature (habitual 
 posture). 
 
 which is also a little less curved; the patient is 
 already much stronger. 
 
 " July 21st. Seventy -first visit for treatment ; 
 examined. The spine is still further improved 
 both in straightness and increased movability ; 
 still the same ' key-note.' 
 
LATERAL CURVATURE OF THE SPINE. 
 
 43 
 
 " July 23rd. Seventy-second and last visit for 
 
 
 
 
 
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 treatment. — A home prescription very similar to 
 that described on p. 31 was given to the patient 
 
44 
 
 TREATMENT OF 
 
 to be practised daily at home for trie next twelve 
 months." 
 
 On December 9th, 1888, more than four months 
 after leaving England, the patient wrote to me as 
 follows : — " I am pleased to say that I keep up 
 very well. I do my exercises either in getting up 
 or during the morning and before going to bed. . . . 
 All my dresses were much too narrow across the 
 chest, and too short in the waist. . . . My general 
 health has much improved, and also one thing I 
 am most thankful for is that those pains I used to 
 have in the left side have entirely disappeared." 
 
 Fio;. 15. 
 
 Tracing of loins midway from ribs to iliac crests, in flexed position of 
 trunk, in same patient as Figs. 13 and 14 (half natural size). 
 
 Case IIT. — Miss M. B., set. sixteen years, the fifth 
 of eight children, all delicate, was sent to me on 
 April 27th, 1888, by the advice of Mr. C. Heath. 
 Her previous history was that three years ago the 
 right shoulder was observed to be " growing out ; " 
 she was at once taken to a surgical instrument 
 maker, who applied a steel spinal support, which 
 was worn for two years. The deformity becoming 
 much worse, the patient consulted a London 
 orthopaedic surgeon, who prescribed another steel 
 spinal support, which was being worn when I was 
 
LATERAL CURVATURE OF THE SPINE. 45 
 
 consulted. The friends described, the patient, as 
 becoming rapidly worse during these three years 
 since they first observed the curvature. Figs. 13, 
 14, 15, sufficiently describe the case, exhibiting as 
 they do the moderate deformity of the right ribs 
 posteriorly aud the severe deformity of the left 
 loin, caused by the rotation backwards of the 
 left transverse processes of the lumbar vertebras, 
 which form a severe lateral curve with convexity 
 to the left. This young lady came for three 
 months' daily treatment. On July 9th, 1888, the 
 father wrote, "I beg to congratulate you on the 
 great success in your treatment of my daughter ; " 
 and on January 12th, 1889, nearly six months after 
 the patient left my personal treatment, he wrote, 
 "I am pleased to tell you that my dear daughter 
 is very much better for the three months' treat- 
 ment under your care. She walks more uprightly, 
 and does not become so easily fatigued as she did 
 before she went under your care. Her deformity 
 is scarcely noticeable now as she walks along, and 
 she is in good health and spirits. ... I was truly 
 delighted for her to leave off that wretched instru- 
 ment which had been made for her by the order of 
 the surgeon she had previously been to, and which 
 was not only a great disfigurement and a very 
 heavy thing for her to be always carrying about 
 her, but never did her the slightest good." 
 
 I would refer medical men who wish to. know 
 more about the results obtained by the treatment 
 here advocated to a series of two hundred con- 
 secutive cases of lateral curvature of the spine 
 
46 TREATMENT OF 
 
 which I had treated without mechanical spinal 
 supports up to April 4th, 1885, and on which I 
 published a paper in the British Medical Journal 
 of October 31st, 1885. In that paper, which I had 
 previously read at the annual meeting of the British 
 Medical Association at Cardiff in 1885, I gave 
 not only a concise description and the results of 
 the treatment of each case, but also the names of 
 the medical men by whom a large proportion of the 
 patients had been sent to me. It will suffice to 
 give the following three extracts from that paper : 
 " In the column headed ' Previous Treatment ' 
 it is interesting to note that many of the cases 
 have been under instrumental treatment for years. 
 Thus case 9 wore a steel support sixteen years ; 
 case 19, a steel support four years, during which 
 period it was screwed up a hundred and ninety- 
 iive times by the surgeon ; case 32 had a steel 
 support seven years ; case 73, a steel support eight 
 years ; case 125, a steel support eighteen years ; 
 case 155, a steel support six years and a poroplastic 
 jacket for a year or two longer; and case 166, a 
 steel support twelve years. From all these cases 
 I removed the spinal support at once, and so 
 strengthened the spinal muscles that the patients 
 were able to hold themselves permanently in a 
 much better position than when wearing the sup- 
 ports, in all cases with much benefit to the general 
 health. 
 
 "In the last column but one the result of my 
 treatment is given as ' improved,' l much improved,' 
 "'very much improved.' I have not ventured to 
 
LATERAL CURVATURE OF THE SPINE. 47 
 
 put down ' cured ' in aDy case, although ' very 
 much improved ' is almost synonymous, because 
 I have ever maintained that any case of lateral 
 curvature of the spine with even a trace of 
 osseous deformity, due to rotation of the lumbar, 
 dorsal, or cervical vertebrae, is to that extent in- 
 curable ; while, on the other hand, some surgeons 
 deny that lateral curvature is present unless there 
 is some permanent rotation of the vertebrae visible 
 externally. 
 
 " Only three cases out of the two hundred are 
 noted as ' not improved,' which was due to defi- 
 cient energy on the part of the patients and 
 neglect to carry out my directions." 
 
 I have therefore given the profession ample 
 material for thoroughly testing the efficacy of the 
 treatment I employ. 
 
 Summary of Prognosis and Treatment. 
 
 1. If osseous deformity be present, even to a 
 slight extent, complete cure of lateral curvature 
 is impossible. 
 
 2. Many cases of apparently severe lateral 
 curvature of the spine have no osseous deformity, 
 and can be at once restored temporarily to a good 
 position. 
 
 The Clinical Society's Committee on Lateral 
 Curvature of the Spine classify all lateral curva- 
 tures as (1) cases without osseous deformity and 
 (2) cases with osseous deformity, according as there 
 is or is not bony deformity present (see their report 
 in vol. xxi. of Clin. Soc. Trans., 1888, p. 301). 
 
48 TREATMENT OF 
 
 3. A patient with confirmed lateral curvature, 
 with or without osseous deformity, is so habituated 
 to the vicious position, that attempts on his or her 
 part to improve the spine, except by the surgeon's 
 directions, generally increase the deformity. 
 
 4. Exercise of the spinal muscles, with or without 
 resistance by the surgeon or a trained assistant; 
 is absolutely necessary to the successful treatment 
 of lateral curvature. 
 
 5. Good positions should be always assumed, 
 not only at meals and at lessons, but whenever 
 otherwise occupied. This is practicable in slight 
 cases with ordinary chairs ; in some cases a couch 
 with horizontal seat and movable and moulded 
 back is useful. 
 
 6. Special attention is to be directed to the 
 dress (including stays, braces, etc.) in both sexes, 
 so that it presents no obstacle to the expansion of 
 the thorax anteriorly and to the patient main- 
 taining an improved or an erect position. 
 
 7. The feet should always be examined in cases 
 of lateral curvature, as "flat-foot" is so frequently 
 concurrent with the spinal deformity, and requires 
 to be attended to at the same time. 
 
 8. A moderate amount of walking and outdoor 
 games and exercise, short of much fatigue, is 
 beneficial. 
 
 9. Lying on the face or back does not tend to 
 cure lateral curvature, as it does not strengthen 
 the spinal muscles. Lying for fifteen or thirty- 
 minutes is useful when it rests the patient ; but if 
 it be continued for several hours daily, only harm 
 
LATERAL CURVATURE OF THE SPINE. 49 
 
 results from the physiological activity of the spinal 
 muscles being prevented. 
 
 10. Sayre's plaster or poroplastic jackets and 
 steel spinal supports are never to be employed 
 except in cases of lateral curvature due to paralysis 
 of the erectores spinas muscles, where the patient is 
 unable by an effort to maintain an improved position 
 of the spine for even a few seconds, and then only 
 with the object of preventing further increase, if 
 possible, in the osseous deformity of the ribs and 
 vertebrae. 
 
 11. The more attention is paid to the avoidance 
 of vicious and to the maintenance of good positions, 
 and the more carefully and conscientiously the 
 patient carries out the prescribed exercises, the 
 better and quicker are the results obtained. 
 
 12. Slight cases of lateral curvature of the spine 
 without any osseous deformity can generally be 
 cured in one month by one hour's daily treatment ; 
 other cases, on an average, require three months' 
 treatment for an hour daily, to effect either a cure 
 in those cases which can be cured (postural, or non- 
 osseous stage), or the utmost improvement pos- 
 sible in others where there is more or less osseous 
 deformity present (osseous stage). 
 
 The age of the patient has little or nothing to do 
 with the success of the treatment I employ ; all 
 that is required is the willing and persevering co- 
 operation of the patient. At the present time 
 (January, 1889) my youngest patient is a little girl 
 three and a half years old, sent me by a Brighton 
 practitioner, who has improved greatly by the 
 
 4 
 
60 TREATMENT OF LATERAL CURVATURE OF THE SPINE. 
 
 course of treatment now almost completed; and 
 last month (December, 1888) I said good-bye to a 
 lady aged fifty-seven years, who had worn steel 
 spinal supports for forty years, the last twenty years 
 under the same London orthopaedic surgeon, and 
 whose pain and suffering were described to me by 
 the son (a medical man) as "incredible in amount." 
 This lady's spinal support I removed at once, and 
 by the end of the three months' treatment she was 
 able to undergo the severest exercises without any 
 pain ; and she has now left me with a strong and ' 
 straighter spine, although a complete cure was 
 out of the question, as there is very considerable 
 osseous deformity of the ribs and vertebra. 
 
 In all cases, constant attention to position and 
 daily perseverance with prescribed exercises are 
 required at home for at least a year afterwards 
 to confirm the cure or improvement and to pre- 
 vent relapse. 
 
 Lastly, the conscientious carrying out for about 
 one hour daily of the treatment I advocate, and 
 which I have briefly detailed above, will enable 
 surgeons to cure or improve the vast majority of 
 cases of lateral curvature of the spine on an average 
 in three months from the commencement of the 
 treatment. 
 
APPENDIX. 
 
 THE TREATMENT OF FLAT-FOOT.* 
 
 Flat-foot is so frequently associated with lateral curvature of 
 the spine that I believe the usefulness of this monograph will 
 be increased by its treatment being also given. 
 
 Flat-foot may be defined as a falling down or giving way 
 of the normal arch of the foot, which may be so slight as to 
 escape notice, except from the discomfort it causes, or be so 
 severe that the whole tarsus presents as great a convexity 
 inward as it ought to present a concavity, with the foot so 
 everted that the internal malleolus touches the ground, while 
 the outer border of the foot is raised, with the sole directed 
 outward, as in some cases of infantile paralysis. 
 - Sir James Paget speaks of " the constant pain and weariness 
 of the lower limbs associated with flat-foot. The feet are elon- 
 gated, flat, low, without insteps ; the heels are too little 
 prominent, the plantar arches sunken, the ankles thick ; the 
 astralagus, navicular and inner cuneiform bones, are below their 
 right level. The pains complained of are those of the muscles 
 and tendons, which are habitually overworked in the task of 
 keeping the body erect when its proper bearings on its supports 
 are disturbed." I consider this description applies to a severe 
 case not due to infantile paralysis. Pain and much deformity 
 are not always associated together ; growing boys and girls 
 approaching puberty are frequently brought to me complaining 
 ■of severe pain in the insteps whose feet exhibit scarcely any 
 deformity. Again, the severest cases of deformity, those due 
 to infantile paralysis, frequently have no pain or discomfort in 
 the feet, although sensation is perfectly normal. Flat-foot is, 
 therefore, a very general term, and requires some sort of clinical 
 classification if surgeons are to come to any agreement on the 
 propei/ treatment. I think the best classification is one I pro- 
 posed some years ago, viz., (1) cases in which it is possible 
 
 * The greater part of this Appendix was read at the meeting of the 
 New York Academy of Medicine, March 1st, 1888, and published in the 
 Medical Uncord, New York, March 17th. 1888. 
 
52 APPENDIX. 
 
 to restore the foot completely to the normal shape by passive 
 manipulation, without any force exerted by the surgeon, or by 
 making the patient stand with the heels raised ; (2) cases where 
 the tarsal bones have become more or less fixed in their displaced 
 positions by shortened ligaments and tendons, osseous deformity 
 of the articulating surfaces, and fibrous or osseous anchylosis, 
 which require forcible manipulation under anaesthetics to restore 
 more or less of a normal arch ; (3) intermediate cases, in which 
 a partial restoration of the tarsal arch is possible without 
 brisement force. 
 
 A few words must be devoted to the causation of flat-foot, 
 to enable us to obtain a correct view of the proper treatment. 
 Mr. Le Gros Clark says, " In reviewing the action of the 
 various muscles around the foot, it is obvious that their attach- 
 ment is designed to preserve the plantar arch, and that such 
 healthy condition must depend in great measure on the evenly 
 balanced action of those muscles upon their several attachments. 
 Thus the peronei and tibial muscles antagonize each other, 
 and the expanded insertion of two of them into the tarsal 
 bones is very instrumental in preserving the transverse as well 
 as the antero-posterior arch." 
 
 I find that all infants on commencing to walk are normally 
 flat-footed, without any tarsal arch, whereas after they have 
 stood and run about a few months, and the leg-muscles have 
 become developed, a perfect arch is formed. I have several 
 times been consulted by an anxious mother about her baby's 
 feet when the child begins to run alone, the normal absence 
 of a tarsal arch being at first exaggerated by a pad of fat 
 opposite the plantar aspect of the tarsus. I have always been 
 able to reassure her, and to tell her that the feet would become 
 arched in time and the adipose instep pad disappear; and the 
 result has proved my prognosis to be correct. 
 
 Anything that tends to weaken the general muscular system 
 during years of growth will also predispose to flat-foot. Thus 
 I find that out of every three cases of lateral curvature of the spine 
 two suffer from flat-foot, and one severely so. Flat-foot is also 
 intimately associated with knock-knee ; the one may follow close 
 on the other, or both deformities may arise simultaneously. 
 
 Injury or chronic disease of one leg, throwing extra work 
 on the sound limb, is also apt to produce flat-foot in the latter. 
 
 Although the bones of the tarsus are apparently so well 
 supported by them ligaments and the tendinous prolongation 
 of the muscles inserted in the sole, yet, as soon as these muscles 
 shirk their work, from weakness or paralysis, undue strain is 
 thrown upon the tarsal ligaments; and they gradually yield, 
 accompanied by more or less aching and pain or none at all, 
 
APPENDIX. 53 
 
 according to the idiosyncrasy of the sufferer. At first there 
 is no osseous malformation, and so long as this is so, more or 
 less complete restoration to the normal is possible ; but in time 
 the articulating surfaces become altered in shape, the bones 
 distorted, and the ligaments so shortened and thickened that 
 even with extreme brisement force, under anaesthetics, only a 
 partial improvement is brought about. Indeed, the production 
 of osseous deformity of the feet is caused in exactly the same 
 way as is that of knock-knee. Flat-foot is therefore directly 
 due to the weakness of the leg-muscles which are attached to the 
 bones of the feet. 
 
 In the treatment of flat-foot we have to aim at the restoration 
 and maintenance of the previously depressed plantar arch and 
 the strengthening of the leg-muscles which tend to produce 
 and preserve the normal arch of the foot. We have therefore 
 to discuss (a) mechanical means for replacing and keeping up 
 the plantar arch, and (&) therapeutic methods for strengthening 
 the weak tibial muscles. 
 
 (a) Mechanical means for replacing and keeping up the plantar 
 arch. — In groups (1) and (3) a boot or shoe should be worn broad 
 enough across the metatarso-phalangeal articulations, best made 
 from a tracing of the stockinged foot ; and if the toes are much 
 deformed or displaced, the stocking should be digitated and the 
 toes well spread out on the ground. The heel of the boot should 
 be low and broad, not more than double the thickness of the sole 
 in front. For raising the depressed arch I employed for many 
 years a pad made of superimposed layers of felt, and this, com- 
 bined with treatment for improving the muscular power, has had 
 good results ; every now and then, however, a case proved very 
 obstinate. For the last three years I have discarded pads alto- 
 gether,' and I no longer advise laced-up boots being worn ; indeed, 
 the more freedom left to the movements of the ankle the better, 
 and I therefore recommend shoes to be worn. Instead of a pad 
 which, if efficient, tends to bruise and irritate the already tender 
 tarsus, I employ an increased thickening of the sole opposite the 
 ball of the great toe and on the inner margin of the heel, 
 according to the method of my friend Mr. H. 0. Thomas, of 
 Liverpool. His theory of the mechanical production of flat-foot 
 appears to me to be the most rational ; it is that in the normally 
 constructed foot the lower end of the tibia is placed too much 
 toward the inner border of the foot, so that the tendency of the 
 tarsal arch is to give way under the pressure of the weight of the 
 body, and has to be constantly combated by the efforts of the strong 
 leg-muscles inserted into the foot. If we had to create a new 
 foot and leg, simply with the view of preventing flat-foot, we 
 should plani the lower end of the tibia rather more toward the 
 
54 APPENDIX. 
 
 outer margin of the foot. The device of the wedge-shaped sole, 
 with the base inside and the apex outside, tilts or rotates the 
 foot on its longitudinal or antero -posterior axis and carries the 
 lower end of the tibia toward the outer margin of the foot, and 
 thus removes all or most of the pressure of the weight of the 
 body as transmitted through the lower end of the tibia from over 
 the tarsal arch, in the same way as in the imaginary newly 
 created foot and leg. The increased thickness of sole is from 
 one-fourth to one-half inch, according to the severity of the case ; 
 an addition of a corresponding one -fourth or one-half inch is added 
 to the inner margin of the heel, and this thickness gradually 
 diminishes to nothing at the outer margin, which should be 
 protected by a thin plate of iron or steel studs to prevent further 
 differences of level of the two halves of the heel from wear. The 
 same remarks apply to the increased thickness of the sole, which 
 gradually tapers to nothing at the tip of the sole, as well as at 
 its outer margin. This wedge-sole can be applied to boots and 
 shoes already worn. I believe that the benefit obtained by 
 valgus pads under the depressed instep is really due to the patient 
 being forced to walk on the outer border of the foot to avoid the 
 discomfort and annoyance of the pad pressing against the tarsal 
 arch. Boots made, and so much advertised, with movable or 
 spring-like waists, are useless, and even injurious if the spring is 
 prolonged to the outer margin of the sole, where the foot ought 
 to rest entirely on the ground. As the chief movement in walking- 
 is at the metatarsophalangeal articulations, it would be an 
 advantage if this portion of the sole could be made of a more 
 yielding leather. 
 
 In group (2), where the displaced arch cannot be replaced 
 except by brisemeni force, I would recommend this being 
 effected by Mr. H. O. Thomas' club-foot wrench, under anaesthetics, 
 and the foot kept in a suitable splint in the improved position till 
 all symptoms of the traumatism have disappeared, and the patient 
 then treated as in groups (1) and (3). 
 
 (b) Therapeutical methods for strengthening the toeak tibial 
 muscles. — I know of no better exercise than walking on the toes 
 with the heels raised an inch or so, taking care that they are not 
 raised too much, for when the longitudinal or long axis of the 
 foot behind the metatarso-phalangeal articulation is raised too 
 vertically there is less work for the muscles, as much of the 
 weight of the body is transmitted directly through the bones of 
 the tarsus and metatarsus standing on end. 
 
 It is a good plan to order the patient to walk fifty steps on the 
 toes before and after each meal. 
 
 The chief exercises I employ are the following : (1) " Standing, 
 toes in, heels out, raising and lowering heels, repeated forty 
 
APPENDIX. 55 
 
 times." The patient stands with or without shoes, with the toes 
 touching and the heels separated, so that the feet are at right 
 angles (i.e., rotation inwards of the legs from the hips) ; he has 
 then to slowly raise the heels and as slowly to lower them, while 
 forcing the ankles outwards as much as possible the whole time. 
 
 (2) " Sitting, foot inward circumduction, repeated forty times." 
 The patient, sitting on the floor or couch, with the back supported 
 and the knees extended, circumducts the foot down, in, up, and 
 out, while the toes are directed inward the whole time ; the knee 
 and hip should be kept perfectly still. The leg should rest on a 
 small pad just above the tendo Achillis, to leave the foot free. 
 
 (3) " Sitting, foot adduction (surgeon resisting) and abduction 
 (patient resisting), repeated twenty times." The patient is 
 placed in the same position as before : the surgeon fixes the leg 
 just above the ankle with one hand while the palm of the other 
 exerts a gradually yielding resistance to the patient's effort to 
 adduct and invert the foot. On the completion of the adduction 
 the patient strives to maintain this position of the foot while 
 gradually yielding to the pressure of the surgeon's hand gently 
 pushing the foot back to the commencing position. 
 
 I sometimes employ another exercise, viz., walking on the 
 outside edges of the feet with the soles directed inward and 
 forward. Patients with flat feet will frequently assume this last 
 position instinctively, to give relief to the overstrained ligaments 
 of a displaced tarsus. 
 
 In cases of extreme weakness of the leg-muscles, rubbing 
 (massage) of the leg-muscles for half an hour once or twice dailv 
 should be employed. For the technique, I can refer those 
 interested to my article, " Massage," in Heath's " Dictionary of 
 Practical Surgery." 
 
 Necessarily in cases of infantile paralysis, where the muscles 
 have completely wasted, only the mechanical portion of the above 
 treatment can be carried out, with the addition of ajn elevating 
 steel spring to lift up the foot, for clearing the ground during 
 walking, if there is foot-drop. 
 
 In all cases due' attention should be paid to the general health, 
 and to the removal of all debilitating causes. 
 
 Such severe treatment as the removal of a wedge-shaped piece 
 of bone from the tarsal arch, under antiseptics, does not appear 
 justifiable; and I have not yet seen a case which offered any 
 reasonable probability of this treatment being of permanent 
 benefit to the mutilated patient. 
 
 The effects of the treatment I advocate begin to be felt within 
 a week or two by the patient ; and I seldom see cases where all 
 pain and discomfort has not disappeared within three or four 
 weeks, some; even within a few days. For the cure of the 
 
56 APPENDIX. 
 
 deformity, even slight cases require several months; and for 
 severe cases I generally find that a year or more of perseverance 
 with the special soles and treatment is necessary. 
 
 I append a typical case, illustrating the treatment above 
 described. 
 
 Mrs. , wife of an M.P., consulted me July 7th, 1884, 
 
 with the following history : Two years ago she began to have 
 discomfort in the feet after walking — " a feeling as if the ankles 
 were too soft." The discomfort increased for six months, when 
 she became a vegetarian ; and for a time the pain in the feet 
 was less. Since then the pain has become gradually worse up 
 to the present. The patient is an active, extremely intellectual 
 woman, fairly well nourished ; she can only walk up and down 
 stairs or a few yards out of doors, and that with considerable 
 discomfort. I found both feet severely flat [intermediate, or 
 group (3)], with the pain and aching just under the arch of the 
 instep, and described as " a dull, aching soreness " which 
 "becomes acute pain at times; " standing causes even more pain 
 than walking. On August 25th — viz., six weeks later — patient 
 wrote, " I am following your prescription as far as I can, and 
 feel much better." Again, on November 18th, four months 
 
 later, " I am a great deal better When I was in London, 
 
 I was trying to school my impatience to resignation to a walk of 
 not more than a hundred yards at a time ; now I can walk two 
 miles without much fatigue, and am astonished at the elasticity 
 and youthfulness of my movements. I consider myself a walking 
 advertisement of your surgical capacity ! " This lady has con- 
 tinued well up to the present time. 
 
 London : H. K. Lewis, 136, Gower Street. 
 
April, 1889. 
 
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Catalogue of Works Published by H. K. Lewis. 
 
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Catalogue of Works Published by H. K. Lewis. 
 
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Catalogue of Works Published by H. K. Lewis, 
 
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 ON DIET AND REGIMEN IN SICKNESS AND 
 
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 MODEL DIAGRAM OP THE ORGANS IN THE 
 
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 THE PHYSIOLOGY OP THE SPECIAL SENSES AND 
 
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Catalogue of Works Published by H. K. Lewis. 
 
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 A MANUAL OF DIETETICS : Large 8vo, ios. 6d. 
 
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 GOUT IN ITS PROTEAN ASPECTS. Post 8vo, 7 s. 6d. 
 
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 PRACTICAL HISTOLOGY AND PATHOLOGY. Third 
 
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 Deputy Inspector General of Hospitals, Army Medical Department. 
 
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Catalogue of Works Published by H. E. Lewis. 
 
 JOHN GORHAM, m.r.c.s. 
 
 TOOTH EXTRACTION : a Manual on the proper mode 
 
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 JOHN W. S. GOULEY, M.D. 
 
 Surgeon to Bellevue Hospital. 
 
 DISEASES OP MAW : Data of tneir Nomenclature, Clas- 
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 DIAGRAMS FOR THE RECORD OP PHYSICAL SIGNS. 
 
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 ALLAN McLANE HAMILTON, m.d. 
 
 THE MODERN TREATMENT OP HEADACHES. 
 
 Square i6mo, 2s. 6d. [Just Published. 
 
10 Catalogue of Works Published by H. K. Lewis. 
 
 WILLIAM A. HAMMOND, m.d. 
 
 Professor of Mental and Nervous Diseases in the Medical Department of the University o> 
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 I. 
 
 A TREATISE ON THE DISEASES OF THE NERVOUS 
 
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 A TREATISE ON INSANITY. Large 8vo, 25s. 
 
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 SPIRITUALISM AND ALLIED CAUSES AND CON- 
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 ALEXANDER HARVEY, m.a., m.d. 
 
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 I. 
 
 FIRST LINES OF THERAPEUTICS; as based on the 
 
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 ON THE FCETUS IN UTERO AS INOCULATING THE 
 
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 ALEXANDER HARVEY, m.d. 
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 OUTLINES OF PICTORIAL DIAGNOSIS OF DIS- 
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Catalogue of Works Published by H. K. Lewis. 11 
 
 C. HIGGENS, f.r.c.s. 
 Ophthalmic Surgeon to Guy's Hospital; Lecturer on Ophthalmology at Guy's Hospital 
 
 Medical School. 
 
 MANUAL OP OPHTHALMIC PRACTICE. 
 
 Crown 8vo, illustrations, 6s. [Now ready. 
 
 [Lewis's Practical Series.] 
 
 BERKELEY HILL, m.b. lond., f.r.c.s. 
 
 Professor of Clinical Surgery in University College ; Surgeon to University College 
 Hospital and to the Lock Hospital. 
 
 THE ESSENTIALS OP BANDAGING. With directions 
 
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 on Surgical Landmarks. Sixth Edition, revised and enlarged, Illustrated 
 by 144 Wood Engravings, crown 8vo, 5s. 
 
 BERKELEY HILL, m.b. lond., f.r.c.s. 
 
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 AND 
 
 ARTHUR COOPER, l.r.cp., m.r.cs. 
 
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 I. 
 
 SYPHILIS AND LOCAL CONTAGIOUS DISORDERS. 
 
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 11. 
 
 THE STUDENT'S MANUAL OP VENEREAL DIS- 
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 THE ABORTIVE TREATMENT OP SPECIFIC FE- 
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 SIR W. JENNER, Bart., m.d. 
 
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 C. M. JESSOP, m.r.cp. 
 
 Associate of King's College, London ; Brigade Surgeon H.M. British Forces. 
 
 ASIATIC CHOLERA, being a Report on an Outbreak 
 
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 map, demy 8vo, 2s. 6d. 
 
12 Catalogue of Works Published by H. K. LewU. 
 
 GEORGE LINDSAY JOHNSON, m.a., m.b., b.c. cantab. 
 
 Clinical Assistant, late House Surgeon and Chloroformist, Royal Westminster Ophthalmic 
 
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 A NEW METHOD OF TREATING CHRONIC GLAU- 
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 INEBRIETY: its Etiology, Pathology, Treatment, and 
 
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 RUSTOMJEE NASERWANJEE KHORY, m.d. brux. 
 
 Member of the Royal College of Physicians. 
 
 THE PRINCIPLES AND PRACTICE OP MEDICINE 
 
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 NORMAN W. KINGSLEY, m.d.s., d.d.s. 
 
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 A TREATISE ON ORAL DEFORMITIES AS A 
 
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 J. WICKHAM LEGG, f.r.c.p. 
 
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 I. 
 
 ON THE BILE, JAUNDICE, AND BILIOUS DISEASE 
 
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 A GUIDE TO THE EXAMINATION OF THE URINE ; 
 
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 III. 
 A TREATISE ON HAEMOPHILIA, SOMETIMES 
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 ARTHUR H. N. LEWERS, m.d, lond., m.r.c.p. lond. 
 
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 Diseases of Women to the Society of Apothecaries of London, &c. 
 
 A PRACTICAL TEXTBOOK OF THE DISEASES OF 
 
 WOMEN. With Illustrations, crown 8vo, 8s. 6d. [Now ready. 
 
 [Lewis's Practical Series.J 
 
Catalogue of Works Published by H. K. Lewis. 13 
 
 LEWIS'S PRACTICAL SERIES. 
 
 Under this title Mr. Lewis is publishing a Series of Monographs, em- 
 bracing the various branches of Medicine and Surgery. 
 
 The volumes are written by well-known Hospital Physicians and Sur- 
 geons, recognized as authorities in the subjects of which they treat. The 
 works are intended to be of a thoroughly practical nature, calculated 
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 most recent information in a compact and readable form. 
 
 MANUAL OF OPHTHALMIC PRACTICE. 
 
 By C. HIGGENS, F.R.C.S., Ophthalmic Surgeon to Guy's Hospital; Lecturer 
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 8vo, 6s. [Now ready. 
 
 A PRACTICAL TEXTBOOK OF THE DISEASES OF WOMEN. 
 
 By ARTHUR H. N. LEWERS, M.D. Lond., M.R.C.P. Lond., Assistant Ob- 
 stetric Physician to the London Hospital ; Examiner in Midwifery and Diseases 
 of Women to the Society of Apothecaries of London, etc. With Illustrations, 
 crown 8vo, 8s. 6d. [Ready. 
 
 AN/ESTHETICS THEIR USES AND ADMINISTRATION. 
 
 By DUDLEY W. BUXTON, M.D., B S., M.R.C.P., Administrator of 
 Anaesthetics in University College Hospital and the Hospital for Women, Soho 
 Square. Crown 8vo, 4s. [Ready. 
 
 TREATMENT OF DISEASE IN CHILDREN: INCLUDING THE OUT- 
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 ON FEVERS: THEIR HISTORY, ETIOLOGY, DIAGNOSIS, PROGNOSIS, 
 
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 HANDBOOK OF DISEASES OF THE EAR FOR THE USE OF STUDENTS 
 
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 A PRACTICAL TREATISE ON DISEASES OF THE KIDNEYS AND 
 
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 cr. 8vo, 8s. 6d. 
 
 Further volumes will be announced in due course. 
 
14 Catalogue of Works Published by H. K. Lewis. 
 
 DR. GEORGE LEWIN. 
 
 Professor at the Fr. With. University, and Surgeon-in-Chief of the Syphilitic Wards and 
 Skin Disease Wards of the ChariU Hospital, Berlin. 
 
 THE TREATMENT OP SYPHILIS WITH SUBCUTA- 
 NEOUS SUBLIMATE INJECTIONS. Translated by Dr. Carl 
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 Small 8vo, 7s. 
 
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 LEWIS'S POCKET MEDICAL VOCABULARY. 
 
 Over 200 pp., 32mo, roan, 3s. 6d. 
 
 T. R. LEWIS, M.B., F.R.S. ELECT, ETC. 
 Late Fellow of the Calcutta University, Surgeon-Major Army Medical Staff, &c. 
 
 PHYSIOLOGICAL AND PATHOLOGICAL RESEAR- 
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 Formerly Assistant Professor of Physiology in Harvard College. 
 
 I. 
 
 EXPERIMENTAL RESEARCHES ON THE REGIONAL 
 
 TEMPERATURE OF THE HEAD, under Conditions of Rest, In- 
 tellectual Activity and Emotion. With Illustrations, 8vo, 8s. 
 
 II. 
 
 ON THE NORMAL TEMPERATURE OP THE HEAD. 
 
 8vo, 5s. 
 
 WILLIAM THOMPSON LUSK, a.m., m.d. 
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 THE SCIENCE AND ART OP MIDWIFERY. 
 
 Third Edition, with numerous Illustrations, 8vo, 18s. 
 
Catalogue of Works Published by H. K. Lewis. 15 
 
 RAWDON MACNAMARA. 
 
 Professor of Materia Medica, Royal College of Surgeons, Ireland ; Senior Surgeon to the 
 
 Westmoreland (Lock) Government Hospital ; Surgeon to the Meath Hospital, etc. 
 
 AN" INTRODUCTION TO THE STUDY OF THE 
 
 BRITISH PHARMACOPOEIA. Demy 32010, is. 6d. [Just published. 
 
 JOHN MACPHERSON, m.d. 
 
 Inspector-General of Hospitals H.M. Bengal Army (Retired). 
 Author of " Cholera xn its Home" &c. 
 
 ANNALS OP CHOLERA PROM THE EARLIEST 
 
 PERIODS TO THE YEAR 1817. With a map. Demy 8vo, 7s. 6d. 
 
 BATH, CONTREXEVILLE, AND THE LIME SUL- 
 
 PHATED WATERS. Crown 8vo, 2s. 6d. 
 
 DR. V. MAGNAN. 
 Physician to St. Ann Asylum, Paris; Laureate of the Institute. 
 
 ON ALCOHOLISM, the Various Forms of Alcoholic 
 
 Delirium and their Treatment. Translated by W. S. Greenfield, 
 M.D., M.R.C.P. 8vo, 7s. 6d. 
 
 A. COWLEY MALLEY, b.a., m.b., b.ch. t.c.d. 
 
 PHOTO-MICROGRAPHY; including a description of 
 
 the Wet Collodion and Gelatino-Bromide Processes, together with the 
 best methods of Mounting and Preparing Microscopic Objects for Photo- 
 Micrography. Second Edition, with Photographs and Illustrations, 
 crown 8vo, 7s. 6d. 
 
 PATRICK MANSON, m.d., cm. 
 Amoy, China. 
 
 THE FILARIA SANGUINIS HOMINIS ; AND CER- 
 TAIN NEW FORMS OF PARASITIC DISEASE IN INDIA, 
 CHINA, AND WARM COUNTRIES. Illustrated with Plates and 
 Charts. 8vo, 10s. 6d. 
 
16 Catalogue of Works Published by 2Z. K. Lewis. 
 
 PROFESSOR MARTIN. 
 
 MARTIN'S ATLAS OP OBSTETRICS AND GYNECO- 
 LOGY. Edited by A. Martin, Docent in the University of Berlin. 
 Translated and edited with additions by Fancourt Barnes, M.D., 
 M.R.C P., Physician to the Chelsea Hospital for Women ; Obstetric 
 Physician to the Great Northern Hospital ; and to the Royal 
 Maternity Charity of London, &c. Medium 4to, Morocco half bound, 
 3 is. 6d. nett. 
 
 WILLIAM MARTINDALE, f.c.s. 
 
 L ate Examiner of the Pharmaceutical Society, and late Teacher of Pharmacy and Demon- 
 strator of Materia Medica at University College. 
 
 AND 
 
 W. WYNN WESTCOTT, m.b. lond. 
 
 Deputy Coroner for Central Middlesex. 
 
 THE EXTRA PHARMACOPOEIA with the additions in- 
 troduced into the British Pharmacopoeia, 1885, with Medical References, 
 and a Therapeutic Index of Diseases and Symptoms. Fifth Edition, 
 revised with numerous additions, limp roan, med. 241110, 7s. 6d. 
 
 WILLIAM MARTINDALE, f.c.s. 
 Late Examiner of the Pharmaceutical Society, &c. 
 
 COCA, COCAINE, AND ITS SALTS: their History, 
 
 Medical and Economic Uses, and Medicinal Preparations. Fcap. 8vo, 2s. 
 
 MATERIA MEDICA LABELS. 
 
 Adapted for Public and Private Collections. Compiled from the British 
 Pharmacopoeia of 1885. The Labels are arranged in Two Divisions : — 
 Division I. — Comprises, with few exceptions, Substances of Organ- 
 ized Structure, obtained from the Vegetable and Animal King- 
 doms. 
 
 Division II. — Comprises Chemical Materia Medica, including Alco- 
 hols, Alkaloids, Sugars, and Neutral Bodies. 
 On plain paper, 10s. 6d. nett. On gummed paper, 12s. 6d. nett. 
 
 * + * Specimens of the Labels, of which there are over 450, will be sent on application. 
 
 S. E. MAUNSELL, l.r.c.s.i. 
 
 Surgeon-Major, Medical Staff. 
 
 NOTES OP MEDICAL EXPERIENCES IN INDIA 
 
 PRINCIPALLY WITH REFERENCE TO DISEASES OF THE 
 EYE. With Map, post 8vo, 3s. 6d. 
 
Catalogue of Works Published by H K. Lewis. 17 
 
 J. F. MEIGS, m.d. 
 
 Consulting Physician to the Children's Hospital, Philadelphia. 
 
 W. PEPPER, m.d. 
 Lecturer on Clinical Medicine in the University of Pennsylvania. 
 
 A PRACTICAL TREATISE ON THE DISEASES OF 
 
 CHILDREN. Seventh Edition, revised and enlarged, roy. 8vo, 28s. 
 
 Wm. JULIUS MICKLE, m.d., f.r.c.p. lond. 
 
 Medical Superintendent, Grove Hall Asylum, London, &c. 
 
 GENERAL PARALYSIS OP THE INSANE. 
 
 Second Edition, enlarged and rewritten, 8vo, 14s. 
 
 ON INSANITY IN RELATION TO CARDIAC AND 
 
 AORTIC DISEASE AND PHTHISIS. Crown 8vo, 3s. 6d. 
 
 KENNETH W. MILLICAN, b.a. cantab., m.r.c.s. 
 
 THE EVOLUTION OP MORBID GERMS: A Contribu- 
 tion to Transcendental Pathology. Cr. 8vo, 3s. 6d. 
 
 ANGEL MONEY, m.d., m.r.c.p. 
 
 Assistant Physician to University College Hospital, and to the Hospital for 
 Children, Great Ormond Street, &c. 
 
 THE STUDENT'S TEXTBOOK OP THE PRACTICE 
 
 OF MEDICINE. Fcap. 8vo, 6s. 6d. [Just Published. 
 
 TREATMENT OP DISEASE IN CHILDREN : IN- 
 CLUDING THE OUTLINES OF DIAGNOSIS AND THE 
 CHIEF PATHOLOGICAL DIFFERENCES BETWEEN CHILD- 
 REN AND ADULTS. Crown 8vo, 10s. 6d. 
 
 [Lewis's Practical Series.] 
 
 E. A. MORSHEAD, m.r.c.s., l.r.cp. 
 Assistant to the Professor of Medicine in University College, London. 
 
 TABLES OP THE PHYSIOLOGICAL ACTION OP 
 
 DRUGS. Fcap. 8vo, is. 
 
18 Catalogue of Works Published by H. K. Lewis. 
 
 A. STANFORD MORTON, m.b., f.r.c.s. eng. 
 
 Surgeon to the Royal South London Ophthalmic Hospital. 
 
 REFRACTION OF THE EYE : Its Diagnosis, and the 
 
 Correction of its Errors. Third Edition, with Illustrations, small 8vo. 
 3S- 
 
 C, W. MANSELL MOULLIN, m.a., m.d. oxon., f.r.c.s. eng. 
 
 Assistant Surgeon and Senior Demonstrator of Anatomy at the London Hospital; formerly 
 Radcliffe Travelling Fellow and Fellow of Pembroke College, Oxford. 
 
 SPRAINS; THEIR CONSEQUENCES AND TREAT- 
 MENT. Crown 8vo, 5s. [Now ready. 
 
 PAUL F. MUNDE, m.d. 
 
 Professor of Gynecology at the New York Polyclinic ; President of the New York Obstetrical 
 Society and, Vice-President of the British Gynecological Society, &c. 
 
 THE MANAGEMENT OF PREGNANCY, PARTURI- 
 TION, AND THE PUERPERAL STATE, NORMAL AND 
 ABNORMAL. Square 8vo, 3s. 6d. {Just Published. 
 
 
 WILLIAM MURRELL, m.d., f.r.c.p. 
 
 Lecturer on Materia Medica and Therapeutics at Westminster Hospital; Examiner in 
 Materia Medica to the Royal College of Physicians of London, etc. 
 
 MASSOTHERAPEUTICS, OR MASSAGE AS A MODE 
 
 OF TREATMENT. Fourth edition, with Illustrations, crown 8vo, 
 4s. 6d. [Just published. 
 
 WHAT TO DO IN CASES OF POISONING. 
 
 Sixth edition, royal 32mo. [In the press. 
 
 in. 
 
 NITRO- GLYCERINE AS A REMEDY FOR ANGINA 
 
 PECTORIS. Crown 8vo, 3s. 6d. 
 
 DR. FELIX von NIEMEYER. 
 
 L ate Professor of Pathology and Therapeutics ; Director of the Medical Clinic of the 
 University of Tubingen. 
 
 TEXT-BOOK OF PRACTICAL MEDICINE, WITH 
 
 PARTICULAR REFERENCE TO PHYSIOLOGY AND PATHO- 
 LOGICAL ANATOMY. Translated from the Eighth German Edi- 
 tion by special permission of the Author, by George H. Humphrey, 
 M.D., and Charles E. Hackley, M.D. Revised edition, 2 vols, 
 large 8vo, 36s. 
 
Catologue of Works Published by H. K. Lewis. 19 
 
 GEORGE OLIVER, m.d., f.r.c.p. 
 
 i. 
 TTT-P TTATJTJOGATE WATERS: Data Chemical and Therapeu- 
 THE cal H tS R n°?s A on E Ihc TcHmate of Harrogate Add^ssed to the 
 Medical Profession. Crown 8vo, with Map of the Wells, 3 s. od. 
 
 ON BEDSIDE URINE TESTING: aClmical Guide to. the 
 
 Observation of Urine in the course of Work. Third Edition, revisea 
 and enlarged, fcap. 8vo, 3s. 6d. 
 
 SAMUEL OSBORN, f.r.c.s. 
 AstisUnt-Surgeon to the Hospital for Women ; Surgeon Royal Naval Artillery Volunteers 
 
 AMBULANCE LECTURES: FIRST AID. With Mus- 
 
 trations, fcap. 8vo, is. 6d. 
 
 AMBULANCE LECTURES?' NURSING. With Illustrations, 
 fcap. 8vo, is. 6d. 
 
 ROBERT W- PARKER. 
 
 Surgeon to the Bast London Hospital for Children, and to the Grosvenor Hospital for 
 ouTgcun w Women and Children. 
 
 rPT?APTTT?OTOMY IN LARYNGEAL DIPHTHERIA, 
 TR AFTER TREATMENT AND COMPLICATIONS. Second Edition. 
 With Illustrations, 8vo, 5s. 
 
 PONGENITAL CLUB-FOOT; ITS NATURE AND 
 TREATMENT With special reference to the subcutaneous division 
 .of Tarsal Ligaments. 8vo, 7s. 6d. 
 
 JOHN S. PARRY, m.d. 
 
 Obstetrician to the Philadelphia Hospital, Vice-President of the Obstetrical and Pathologi- 
 uosiarii.^ ^ Societies of Philadelphia, &c. 
 
 TPTTTRA-UTERINE PREGNANCY ; Its Causes, Species, 
 Pathological Anatomy, Clinical History, Diagnosis, Prognosis and 
 
 Treatment. 8vo, 8s 
 
20 Catalogue of Works Published by H. K. Lewis. 
 
 E. RANDOLPH PEASLEE, m.d., ll.d. 
 
 Late Professor of Gynecology in the Medical Department of Dartmouth College ; President 
 of the New York Academy of Medicine, &c, &c. 
 
 OVARIAN TUMOURS : Their Pathology, Diagnosis, and 
 
 Treatment, especially by Ovariotomy. Illustrations, roy. 8vo, 16s. 
 
 G. V. POORE, M.D., F.R.C.P. 
 
 Professor of Medical Jurisprudence, University College; Assistant Physician to, and Physi- 
 cian in charge of the Throat Department of, University College Hospital. 
 
 LECTURES ON THE PHYSICAL EXAMINATION OP 
 
 THE MOUTH AND THROAT. With an Appendix of Cases. 8vo, 
 3s. 6d. 
 
 R. DOUGLAS POWELL, m.d., f.r.c.p., m.r.c.s. 
 
 Phytician Extraordinary to H.M. the Queen ; Physician to the Middlesex Hospital and 
 Physician to the Hospital for Consumption and Diseases of the Chest at Brompton. 
 
 DISEASES OP THE LUNGS AND PLEURA, INCLUD- 
 ING CONSUMPTION. Third edition, entirely rewritten and en- 
 larged. With coloured plates and wood engravings, 8vo, 16s. 
 
 URBAN PRITCHARD, m.d. edin., f.r.c.s. eng. 
 
 Professor of Aural Surgery at King's College, London ; Aural Surgeon to King's College 
 Hospital ; Senior Surgeon to the Royal Ear Hospital. 
 
 HANDBOOK OP DISEASES OP THE EAR FOR THE 
 
 USE OF STUDENTS AND PRACTITIONERS. With Illustra- 
 tions, crown 8vo, 4s. 6d. 
 
 [Lewis's Practical Series.] 
 
 CHARLES W. PURDY, m.d. (queen's univ.) 
 
 Professor of Genito-Urinary and Renal Diseases in the Chicago Polyclinic, &c, &c. 
 
 BRIGHT'S DISEASE AND THE ALLIED AFFECTIONS 
 
 OF THE KIDNEYS. With Illustrations, large 8vo, 8s. 6d. 
 
 CHARLES HENRY RALFE, m.a., m.d. cantab., f.r.c.p. lond. 
 
 Assistant Physician to the London Hospital; Examiner in Medicine to the University of 
 Durham, etc., etc. 
 
 A PRACTICAL TREATISE ON DISEASES OP THE 
 
 KIDNEYS AND URINARY DERANGEMENTS. With Illustra- 
 tions, crown 8vo, 10s. 6d. 
 
 [Lewis's Practical Series.] 
 
Catalogue of Works Published by H. K. Lewis. 21 
 
 AMBROSE L. RANNEY, a.m., m.d. 
 
 Professor of the Anatomy and Physiology of the Nervous System in the New York P ost- 
 
 Graduate Medical School and Hospital ; Professor of Nervous and Mental Diseases 
 
 in the Medical Department of the University of Vermont. 
 
 THE APPLIED ANATOMY OP THE NERVOUS SYS- 
 TEM. Being a Study of this portion of the Human Body from a 
 stand-point of its general interest and practical utility in Diagnosis, 
 designed for use as a text-book and a work of reference. Second edit., 
 238 Illustrations, large 8vo, 21s. [?««* published. 
 
 H. A. REEVES, f.r.c.s. edin. 
 
 Senior Assistant Surgeon and Teacher of Practical Surgery at the London Hospital; 
 
 Surgeon to the Royal Orthopadic Hospital. 
 
 BODILY DEFORMITIES AND THEIR TREATMENT: 
 A HANDBOOK OF PRACTICAL ORTHOPEDICS. With 
 numerous Illustrations, crown 8vo, 8s. 6d. 
 
 [Lewis's Practical SeriesJ. 
 
 RALPH RICHARDSON, m.a., m.d. 
 
 Fellow of the College of Physicians, Edinburgh. 
 
 ON THE NATURE OP LIFE: An Introductory Chap- 
 ter to Pathology. Second edition, revised and enlarged. Fcap. 4to, 
 10s. 6d. 
 
 W. RICHARDSON, m.a., m.d., m.r.c.p. 
 
 REMARKS ON DIABETES, ESPECIALLY IN REFER- 
 ENCE TO TREATMENT. Demy 8vo, 4s. 6d. 
 
 SAMUEL RIDEAL, d.sc. (lond.), f.i.c, f.c.s., f.g.s. 
 
 Fellow of University College, London. 
 
 PRACTICAL ORGANIC CHEMISTRY; The Detection 
 
 and Properties of some of the more important Organic Compounds. 
 i 2 mo, 2s. 6d. {J ust Published. 
 
 E. A. RIDSDALE. 
 
 Associate of the Royal School of Mines. 
 
 COSMIC EVOLUTION ; being Speculations on the Origin 
 
 of our Environment. Fcap. 8vo, 3s. [Just published. 
 
22 Catalogue of Works Published by H. K. Lewis. 
 
 SYDNEY RINGER, m.d., f.r.s. 
 
 Professor of the Principles and Practice of Medicine in University College ; Physician to 
 and Professor of Clinical Medicine in, University College Hospital. 
 
 A HANDBOOK OF THEEAPEUTICS. Twelfth Edition, 
 
 thoroughly revised, 8vo, 15s. [Just published. 
 
 ON" THE TEMPERATURE OP THE BODY AS 
 
 A MEANS OF DIAGNOSIS AND PROGNOSIS IN PHTHISIS. 
 Second edition, small 8vo, 2s. 6d. 
 
 FREDERICK T. ROBERTS, m.d., b.sc, f.r.c.p. 
 
 Examiner in Medicine at the University of London; Professor of Therapeutics and of 
 Clinical Medicine in University College ; Physieian to University College Hos- 
 pital ; Physician to Brompton Consumption Hospital, &c. 
 
 I. 
 
 A HANDBOOK OP THE THEORY AND PRACTICE 
 
 OF MEDICINE. Seventh edition, with Illustrations, in one volume, 
 large 8vo, 21s. [just published. 
 
 *#* Copies may also be had bound in two volumes cloth for is. 6d. extra. 
 
 THE OFFICINAL MATERIA MEDICA. 
 
 Second edition, entirely rewritten in accordance with the latest British 
 Pharmacopoeia, fcap. 8vo, 7s. 6d. 
 
 R. LAWTON ROBERTS, m.d., m.r.c.s. 
 
 Honorary Life Member of, and Lecturer and Examiner to, the St. John Ambulance 
 Association. 
 
 ILLUSTRATED LECTURES ON AMBULANCE WORK. 
 
 Third edition copiously Illustrated, crown 8vo, 2s. 6d. • \_Now ready. 
 
 D. B. St. JOHN ROOSA, m.a., m.d. 
 
 Professor of Diseases of the Eye and Ear in the University of the City of New York; Surgeon 
 to the Manhattan Eye and Ear Hospital. 
 
 A PRACTICAL TREATISE ON THE DISEASES OF 
 
 THE EAR, including the Anatomy of the Organ. Sixth edition, 
 Illustrated by wood engravings and chromo-lithographs, large 8vo, 25s. 
 
Catalogue of Works Published by H. K. Lewis. 23 
 
 ROBSON ROOSE, m.d. 
 
 Fellow of the Royal College of Physicians in Edinburgh. 
 i. 
 
 GOUT, AND ITS RELATIONS TO DISEASES OF 
 
 THE LIVER AND KIDNEYS. Sixth Edition, crown 8vo. 
 
 [In the press. 
 ii. 
 NERVE PROSTRATION AND OTHER FUNCTIONAL 
 
 DISORDERS OF DAILY LIFE. Crown 8vo, ios. 6d. 
 
 [Just published. 
 
 J, BURDON SANDERSON, m.d., ll.d., f.r.s. 
 
 Jodrell Professor of Physiology in University College, London. 
 
 UNIVERSITY COLLEGE COURSE OF PRACTICAL 
 
 EXERCISES IN PHYSIOLOGY. With the co-operation of F. J. M. 
 Page, B.Sc, F.C.S. ; W. North, B.A., F.C.S., and Aug. Waller, M.D. 
 Demy 8vo, 3s. 6d. 
 
 W. H. O. SANKEY, m.d. lond., f.r.c.p. 
 
 Late Lecturer on Mental Diseases, University College, London, etc. 
 
 LECTURES ON MENTAL DISEASE. Second Edition, with 
 coloured plates, 8vo, 12s. 6d. 
 
 JOHN SAVORY. 
 
 Member of the Society of Apothecaries, London. 
 
 A COMPENDIUM OF DOMESTIC MEDICINE AND 
 
 COMPANION TO THE MEDICINE CHEST: Intended as a 
 source of easy reference for Clergymen, Master Mariners, and Tra- 
 vellers ; and for Families resident at a distance from professional assist- 
 ance. Tenth Edition, sm. 8vo, 5s. 
 
 EMIL SCHNEE, m.d. 
 
 Consulting Physician at Carlsbad. 
 
 DIABETES, ITS CAUSES AND PERMANENT CURE ; 
 
 from the standpoint of experience and scientific investigation. Trans- 
 lated from the German by R. L. Tafel, A.M., Ph.D. Demy 8vo, 6s. 
 
 [Just published. 
 
24 Catalogue of Works Published by H. K. Lewis. 
 
 DR. B. S. SCHULTZE. 
 
 Professor of Gynecology ; Director of the Lying-in Hospital, and of the Gynecological 
 
 Clinic at Jena. 
 
 THE PATHOLOGY ATTD TREATMENT OP DIS- 
 PLACEMENTS OF THE UTERUS. Translated by J. J. Macan, 
 M.A., M.R.C.S. and edited by A. V. Macan, M.B., M.Ch., Master of 
 the Rotunda Lying-in Hospital, Dublin. With 120 Illustrations, medium 
 8vo, 12s. 6d. {Now ready. 
 
 JOHN V. SHOEMAKER, a.m., m.d. 
 
 Professor of Skin Diseases in the Medico-Chirurgical College and Hospital of Philadelphia ; 
 Physician to the Philadelphia Hospital for Diseases of the Skin. 
 
 A PRACTICAL TREATISE ON DISEASES OP THE 
 
 SKIN. Coloured Plates and other Illustrations, large 8vo, 24s. 
 
 WM. JAPP SINCLAIR, m.a., m.d. 
 
 Honorary Physician to the Manchester Southern Hospital for Women and Children, and 
 
 Manchester Maternity Hospital. 
 
 ON GONORRHEAL INFECTION IN WOMEN. 
 
 Post 8vo, 4s. [Just published. 
 
 A. J. C. SKENE, m.d. 
 
 Professor of Gynecology in the Long Island College Hospital, Brooklyn, New York. 
 
 TREATISE ON THE DISEASES OP WOMEN, FOR 
 
 THE USE OF STUDENTS AND PRACTITIONERS. Nine 
 coloured plates and 251 engravings, large 8vo, 28s. 
 
 ALDER SMITH, m.b. lond., f.r.c.s. 
 
 Resident Medical Officer, Christ's Hospital, London. 
 
 RINGWORM : Its Diagnosis and Treatment. 
 
 Third Edition, enlarged, with Illustrations, fcap. 8vo, 5s. 6d. 
 
 J. LEWIS SMITH, m.d. 
 
 Physician to the New York Infants' Hospital; Clinical Lecturer on Diseases of Children 
 in Bellevue Hospital Medical College. 
 
 A TREATISE ON THE DISEASES OP INFANCY 
 
 AND CHILDHOOD. Fifth Edition, with Illustrations, large 8vo, 21s. 
 
Catalogue of Works Published by H. K. Lewis. 25 
 
 FRANCIS W. SMITH, m.b., b.s. 
 
 THE SALINE WATERS OP LEAMINGTON. Second Edit., 
 with Illustrations, crown 8vo, is. nett. 
 
 JOHN KENT SPENDER, m.d. lond. 
 
 Physician to the Royal Mineral Water Hospital, Bath. 
 
 THE EARLY SYMPTOMS AND THE EARLY TREAT- 
 MENT OF OSTEO-ARTHRITTS, commonly called Rheumatoid 
 Arthritis, with special reference to the Bath Thermal Waters. Sm. 8vo. 
 2s. 6d. [Just published. 
 
 JAMES STARTIN, m.b., m.r.c.s. 
 
 Surgeon and Joint Lecturer to St. John's Hospital for Diseases of the Skin. 
 
 LECTURES ON THE PARASITIC DISEASES OP 
 
 THE SKIN. VEGETOID AND ANIMAL. With Illustrations, 
 crown 8vo, 2s. 6d. 
 
 W. R. H. STEWART, f.r.c.s., l.r.c.p. edin. 
 
 Aural Surgeon to the Great Northern Central Hospital; Surgeon to the London Throat 
 
 Hospital, &c. 
 
 EPITOME OP DISEASES AND INJURIES OP THE 
 
 EAR, with a Chapter on Naso- Pharyngeal Diseases causing Deafness. 
 Demy 321x10, 2s. 6d. [Just published. 
 
 LEWIS A. STIMSON, b.a., m.d. 
 
 Surgeon to the Presbyterian and Bellevue Hospitals ; Professor of Clinical Surgery in the 
 Medical Faculty of the University of the City of New York, &c. 
 
 A MANUAL OP OPERATIVE SURGERY. 
 
 Second Edition, with three hundred and forty-two Illustrations, post 
 8vo, 10s. 6d. 
 
 ADOLF STRUMPELL. 
 Director of the Medical Clinic in the University of Erlangen. 
 
 TEXT-BOOK OP MEDICINE FOR STUDENTS 
 
 AND PRACTITIONERS. Translated from the latest German edition 
 by Dr. H. F. Vickery and Dr. P. C. Knapp, with Editorial Notes by 
 Dr. F. C. Shattuck, Visiting Physician to the Massachusetts General 
 Hospital, etc. Complete in one large vol., imp. 8vo, with in Illustra- 
 tions, 28s. 
 
26 Catalogue of Works Published by H. K. Lewis. 
 
 JUKES DE STYRAP, m.k.q.c.p., etc. 
 
 Physician-Extraordinary, late Physician in Ordinary, to the Salop Infirmary ; Consulting 
 Physician to the South Salop and Montgomeryshire Infirmaries, etc. 
 
 THE MEDICO-CHIRURGICAL TARIFFS PREPARED 
 
 FOR THE LATE SHROPSHIRE ETHICAL BRANCH OF THE 
 BRITISH MEDICAL ASSOCIATION. Fourth Edition, fcap. 4to, 
 revised and enlarged, 2s. nett. 
 
 C W. SUCKLING, m.d.lond., m.r.c.p. 
 
 Professor of Materia Medica and Therapeutics at the Queen's College, Physician to the 
 Queen's Hospital, Birmingham, etc. 
 
 ON THE DIAGNOSIS OF DISEASES OF THE 
 
 BRAIN, SPINAL CORD, AND NERVES. With Illustrations, 
 crown 8vo, 8s. 6d. 
 
 JOHN BLAND SUTTON, f.r.c.s. 
 
 Lecturer on Comparative A natomy, Senior Demonstrator of A natomy, and Assistant Surgeon 
 
 to the Middlesex Hospital ; Erasmus Wilson Lecturer, Royal College of 
 
 Surgeons, England. 
 
 LIGAMENTS : THEIR NATURE AND MORPHOLOGY. 
 
 With numerous Illustrations, post 8vo, 4s. 6d. 
 
 HENRY R. SWANZY, a.m., m.b., f.r.c.s.i. 
 
 Examiner in Ophthalmic Surgery in the Royal University of Ireland, and to the Conjoint 
 
 Board of the King and Queen's College of Physicians and Royal College of 
 
 Surgeons, Ireland ; Surgeon to the National Eye and Ear 
 
 Infirmary, Dublin, etc. 
 
 A HANDBOOK OF THE DISEASES OF THE EYE AND 
 
 THEIR TREATMENT. Second Edition, Illustrated with wood- 
 engravings, colour tests, etc., small 8vo, 10s. 6d. [Just published. 
 
 EUGENE S. TALBOT, m.d., d.d.s. 
 
 Professor of Dental Surgery in the Woman's Medical College ; Lecturer on Dental 
 Pathology and Surgery in Rush Medical College, Chicago. 
 
 IRREGULARITIES OF THE TEETH AND THEIR 
 
 TREATMENT. With 152 Illustrations, royal 8vo, 10s. 6d. 
 
 JOHN DAVIES THOMAS, m.d. lond., f.r.c.s. eng. 
 Physician to the Adelaide Hospital, S. Australia, 
 
 I. 
 
 HYDATID DISEASE, WITH SPECIAL REFERENCE 
 
 TO ITS PREVALENCE IN AUSTRALIA. Demy 8vo, 10s. 6d. 
 
 II. 
 HYDATID DISEASE OF THE LUNGS. Demy 8vo, 2s. 
 
Catalogue of Works Published by H. K. Lewis. 27 
 
 HUGH OWEN THOMAS, m.r.c.s. 
 
 DISEASES OP THE HIP, KNEE, AND ANKLE 
 
 JOINTS, with their Deformities, treated by a new and efficient method. 
 Third Edition, 8vo, 25s. 
 
 II. 
 
 CONTRIBUTIONS TO SURGERY AND MEDICINE :- 
 
 Part i.— Intestinal Obstruction ; with an Appendix on the Action of 
 Remedies. 10s. 
 2 . The Principles of the Treatment of Joint Disease, Inflamma- 
 tion, Anchylosis, Reduction of Joint Deformity, Bone Set- 
 ting. 5s. 
 3 ._Fractures, Dislocations, Diseases and Deformities of the 
 
 Bones of the Trunk and Upper Extremities. 10s. 
 4.— The Collegian of 1666 and the Collegians of 1885 ; or what is 
 recognised treatment ? Second Edition, is. 
 „ 5.— On Fractures of the Lower Jaw. is. 
 
 6.— The Principles of the Treatment of Fractures and Disloca- 
 tions. 10s. 
 „ 8.— The Inhibition of Nerves by Drugs. Proof that Inhibitory 
 Nerve-Fibres do not exist, is. 
 (Parts 7, 9 and 10 are in preparation). 
 
 J. ASHBURTON THOMPSON, m.r.c.s. 
 
 Late Surgeon at King's Cross to the Great Northern Railway Company. 
 
 PREE PHOSPHORUS IN MEDICINE WITH SPE- 
 CIAL REFERENCE TO ITS USE IN NEURALGIA. A contribution 
 to Materia Medica and Therapeutics. An account of the History, Phar- 
 maceutical Preparations, Dose, Internal Administration, and Therapeu- 
 tic uses of Phosphorus ; with a Complete Bibliography of this subject, 
 referring to nearly 200 works upon it. Demy 8vo, 7s. 6d. 
 
 J. C. THOROWGOOD, m.d. 
 Assistant Physician to the City of London Hospital for Diseases of the Chest. 
 
 THE CLIMATIC TREATMENT OP CONSUMPTION 
 
 AND CHRONIC LUNG DISEASES. Third Edition, post 8vo, 3s 6d. 
 
28 Catalogue of Works Published by H. K. Lewis. 
 
 FREDERICK TREVES, f.r.c.s. 
 
 Hunterian Professor at the Royal College of Surgeons of England ; Surgeon to and Lecturer 
 on Anatomy at the London Hospital. 
 
 THE ANATOMY OP THE INTESTINAL CANAL AND 
 
 PERITONEUM IN MAN. Hunterian Lectures, 1885. 4to, 2s. 6d. 
 
 D. HACK TUKE, m.d., ll.d. 
 Fellow of the Royal College of Physicians, London. 
 
 THE INSANE IN THE UNITED STATES AND 
 
 CANADA. Demy 8vo, 7s. 6d. 
 
 LAURENCE TURNBULL, m.d., ph.g. 
 
 Aural Surgeon to Jefferson Medical College Hospital, &c, &c. 
 
 ARTIFICIAL ANESTHESIA : A Manual of Anaesthetic 
 
 Agents, and their Employment in the Treatment of Disease. Second 
 Edition, with Illustrations, crown 8vo, 6s. 
 
 DR. R. ULTZMANN. 
 
 ON STERILITY AND IMPOTENCE IN MAN. Translated 
 from the German with notes and additions by Arthur Cooper, L.R.C.P., 
 M.R.C.S., Surgeon to the Westminster General Dispensary. With Illus- 
 trations, fcap. 8vo, 25. 6d. 
 
 W. H. VAN BUREN, m.d., ll.d. 
 Professor of Surgery in the Bellevue Hospital Medical College. 
 
 DISEASES OP THE RECTUM: And the Surgery of 
 
 the Lower Bowel. Second Edition, with Illustrations, 8vo, 14s. 
 
 RUDOLPH VIRCHOW, m.d. 
 
 Professor in the University, and Member of the Academy of Sciences of Berlin, &c, 6-c. 
 
 INFECTION - DISEASES IN THE ARMY, Chiefly 
 
 Wound Fever, Typhoid, Dysentery, and Diphtheria. Translated from 
 the German by John James, M.B., F.R.C.S. Fcap. 8vo, is. 6d. 
 
Catalogue of Works Published by H. K. Lewis, 29 
 
 ALFRED VOGEL, m.d. 
 
 Professor of Clinical Medicine in the University of Dorp at, Russia. 
 
 A PRACTICAL TREATISE ON THE DISEASES OF 
 CHILDREN Third Edition, translated and edited by H. Raphael, 
 M.D., from the Eighth German Edition, illustrated by six lithographic 
 plates, part coloured, royal 8vo, 18s. 
 
 A. DUNBAR WALKER, m.d., cm. 
 
 THE PARENT'S MEDICAL NOTE BOOK. Oblong post 8vo, 
 cloth, is. 6d. 
 
 JOHN RICHARD WARDELL, m.d. edin., f.r.c.p. lond. 
 Late Consulting Physician to the General Hospital Tunbridge Wells. 
 
 CONTRIBUTIONS TO PATHOLOGY AND THE PRAC- 
 
 TICE OF MEDICINE. Medium 8vo, 21s. 
 
 W SPENCER WATSON, f.r.c.s. eng., b.m. lond. 
 Surgeon to the Great Northern Hospital ;££?«£ to the Roval South L ° nd ° n °P hthalnttc 
 
 DISEASES OP THE NOSE AND ITS ACCESSORY 
 
 CAVITIES. Profusely Illustrated. Demy 8vo, 18s. 
 
 II. 
 EYEBALL-TENSION: Its Effects on the Sight and its 
 
 Treatment. With woodcuts, p. 8vo, 2s. 6d. 
 
 III. 
 ON ABSCESS AND TUMOURS OP THE ORBIT. Post 
 
 8vo, 2s. 6d. 
 
 FRANCIS H. WELCH, f.r.c.s. 
 
 Surgeon Major, A. M.D. 
 
 VNTERIC FEVER : as Illustrated by Army Data at Home 
 and Abroad ifsPr^Slence and Modifications, Etiology, Pathology and 
 Treatment. 8vo, 5s. fid. 
 
30 Catalogue of Works Published by H. K. Lewis. 
 
 W. WYNN WESTCOTT, m.b. 
 Deputy Coroner for Central Middlesex. 
 
 SUICIDE; its History, Literature, Jurisprudence, and 
 
 Prevention. Crown 8vo, 6s. 
 
 E. G. WHITTLE, m.d. lond., f.r.c.s. eng. 
 
 Senior Surgeon to the Royal Alexandra Hospital for Sick Children, Brighton. 
 
 CONGESTIVE NEURASTHENIA, OR INSOMNIA AND 
 
 NERVE DEPRESSION. Crown 8vo, 3s. 6d. 
 
 [Just published. 
 
 JOHN WILLIAMS, m.d., f.r.c.p. 
 
 Professor of Midwifery in University College, London ; Obstetric Physician to University 
 College Hospital ; Physician Accoucheur to H.R.H. Princess Beatrice, etc. 
 
 CANCER OP THE UTERUS : Being the Harveian Lec- 
 tures for 1886. Illustrated with Lithographic Plates, royal 8vo, 10s. 6d. 
 
 E. T. WILSON, b.m. oxon., f.r.c.p. lond. 
 
 Physician to the Cheltenham General Hospital and Dispensary. 
 
 DISINFECTANTS AND HOW TO USE THEM. In 
 
 Packets of one doz. price is. 
 
 DR. F. WINCKEL. 
 
 Formerly Professor and Director of the Gynecological Clinic at the University of Rostock. 
 
 THE PATHOLOGY AND TREATMENT OP CHILD- 
 BED : A Treatise for Physicians and Students. Translated from the 
 Second German edition, with many additional notes by the Author, 
 by J. R. Chadwick, M.D. 8vo, 14s. 
 
 BERTRAM C. A. WINDLE, m.a., m.d. dubl. 
 Professor of Anatomy in the Queen's College, Birmingham. 
 
 A HANDBOOK OP SURFACE ANATOMY AND LAND- 
 MARKS. Post 8vo, illustrations, 3s. 6d. 
 
Catalogue of Works Published by H. K, Lewis. 31 
 
 EDWARD WOAKES, m.d. lond. 
 
 Senior Aural Surgeon and Lecturer on Aural Surgery at the London Hospital ; Surgeon 
 to the London Throat Hospital. 
 
 ON DEAFNESS, GIDDINESS AND NOISES IN THE 
 
 HEAD. 
 
 Vol. I.— POST-NASAL CATARRH, AND DISEASES OF THE NOSE 
 CAUSING DEAFNESS. With Illustrations, cr. 8vo, 6s. 6d. 
 
 Vol. II.— ON DEAFNESS, GIDDINESS AND NOISES IN THE 
 HEAD. Third Edition, with Illustrations, cr. 8vo. \In preparation. 
 
 NASAL POLYPUS: WITH NEURALGIA, HAY-FEVER, 
 
 AND ASTHMA, IN RELATION TO ETHMOIDITIS. With 
 Illustrations, cr. 8vo, 4s. 6d. 
 
 DAVID YOUNG, m.c, m.b., m.d. 
 
 Licentiate of the Royal College of Physicians, Edinburgh ; Licentiate of the Royal College 
 of Surgeons, Edinburgh, etc. 
 
 ROME IN WINTER AND THE TUSCAN HILLS IN 
 
 SUMMER. A Contribution to the Climate of Italy. Small 
 8vo, 6s. 
 
 HERMANN VON ZEISSL, m.d. 
 Late Professor at the Imperial Royal University of Vienna^ 
 
 OUTLINES OF THE PATHOLOGY AND TREAT- 
 MENT OF SYPHILIS AND ALLIED VENEREAL DISEASES. 
 Second Edition, revised by M. von Zeissl, M.D., Privat-Docent for 
 Diseases of the Skin and Syphilis at the Imperial Royal University of 
 Vienna. Translated, with Notes, by H. Raphael, M.D., Attending 
 Physician for Diseases of Genito-Urinary Organs and Syphilis, Bellevue 
 Hospital, Out-Patient Department. Large 8vo, 18s. [Just published. 
 
 Clinical Charts For Temperature Observations, etc. 
 
 Arranged by W. Rigden, M.R.C.S. 50s. per 1000, 28s. per 500, 
 15s. per 250, 7s. per 100, or is. per dozen. 
 
 Each Chart is arranged for four weeks, and is ruled at the back for making notes of 
 cases; they are convenient in size, and are suitable both for hospital and private practice. 
 
32 Catalogue of Works Published by H. K. Lewis. 
 
 THE NEW SYDENHAM SOCIETY'S PUBLICATIONS. 
 
 President: — W. T. Gairdner, M.D., LL.D. 
 
 Honorary Secretary : — Jonathan Hutchinson, Esq., F.R.S. 
 
 Treasurer: — W. Sedgwick Saunders, M.D., F.S.A. 
 
 Annual Subscription, One Guinea. 
 
 The Society issues translations of recent standard works by continental authors on sub- 
 jects of general interest to the profession. 
 
 Amongst works recently issued are " Spiegelberg's Midwifery," " Hirsch's Historical and 
 Geographical Pathology," "Essays on Micro-Parasites," works by Charcot, Duchenne, 
 Begbie, Billroth, Graves, Koch, Hebra, Guttmann, etc. 
 
 The Society also has in hand an Atlas of Pathology with Coloured Plates, and a valu- 
 able and exhaustive " Lexicon of Medicine and the Allied Sciences." 
 
 The Annual Report, with full list of works published, and all further information will be 
 sent on application. 
 
 PERIODICAL WORKS PUBLISHED BY H. K. LEWIS. 
 
 THE BRITISH JOURNAL OF DERMATOLOGY. Edited by Malcolm Morris and 
 H. G. Brooke. Published monthly, is. Annual Subscription, 12s. post free. 
 
 THE NEW YORK MEDICAL JOURNAL. A Weekly Review of Medicine. Annual 
 Subscription, One Guinea, post free. 
 
 THE THERAPEUTIC GAZETTE. A Monthly Journal, devoted to the Science of 
 Pharmacology, and to the introduction of New Therapeutic Agents. Edited by Drs. H 
 C. Wood and R. M. Smith. Annual Subscription, 10s., post free. 
 
 THE GLASGOW MEDICAL JOURNAL. Published Monthly. Annual Subscription, 
 20s., post free. Single numbers, 2s. each. 
 
 LIVERPOOL MEDICO-CHIRURGICAL JOURNAL, including the Proceedings of 
 the Liverpool Medical Institution. Published twice yearly, 3s. 6d. each number. 
 
 THE INDIAN MEDICAL JOURNAL. A Journal of Medical and Sanitary Science 
 specially devoted to the Interests of the Medical Services. Annual Subscription, 24s 
 post free. 
 
 TRANSACTIONS OF THE COLLEGE OF PHYSICIANS OF PHILADELPHIA 
 Volumes I. to VI., 8vo, 10s. 6d. each. 
 
 MIDDLESEX HOSPITAL, REPORTS OF THE MEDICAL, SURGICAL, AND 
 Pathological Registrars for 1883 to 1886. Demy 8vo, 2s. 6d. nett each volume. 
 
 « * Mr. Lewis is in constant communication with the leading publishing 
 firms in America, and has transactions with them for the sale of his pub- 
 lications in that country. Advantageous arrangements are made in the 
 interests of Authors for the publishing of their works in the United States. 
 
 Mr. Lewis's publications can be procured of all Booksellers in any part of 
 the world. 
 
 London; Printed by H. K. Lewis, 136 Gower Street, W.C. 
 

 
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